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RC669.B54  1907   Heart  disease  and  bl 


RECAP 


flEART  DISEASE 


and 


BLOOD  PRESSURE 


L.  F,  BISHOP 


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HEART  DISEASE 

AND 

BLOOD-PRESSURE 

4. 

^  Practical  Consideration  of  Theory 

and 
Treatment 


BY 

LOUIS  FAUGERES  BISHOP,  A.  M.,  M.  D. 

Clinical  Professor  of  Heart  and  Circulatory  Diseases,  Fordham  Univer- 
sity, School  of  Medicine,   New  York    City  j   Physician   to   the 
Lincoln    Hospital  j     Late    Chairman    of    the    Section    on 
Medicine  of  the  New  York  Academy  of  Medicine  j 
Member  of  the  New  York  Pathological  Society  j 
the     Neurological    Society ;     Alumni   Asso- 
ciation,  St.    Luke's    Hospital,   etc. 


SECOND  EDITION 

mew  lorft 

E.   B.   TREAT   &   COMPANY 

241-243  West  23d  Street 
1907 


COPYRI.GHT 

By  e.  b.  treat  &  CO. 

1904  and  1907 


PREFACE  TO  SECOND  EDITION 

During  the  four  years  that  have  elapsed 
since  the  first  edition  of  this  book  was  written 
a  wide  interest  in  the  subject  has  developed, 
and  the  concentration  of  the  work  of  the 
author  on  the  heart  and  circulation  as  a  spe- 
cialty has  resulted  in  certain  further  conclusions 
which  he  is  anxious  to  submit  to  the  judgment 
of  those  who  received  so  kindly  the  first 
edition.  In  a  chapter  on  "The  Vessel  Tone- 
maintaining  Function  of  the  Central  Nervous 
System"  will  be  found  a  physiological  doctrine 
which  does  not  appear  in  the  literature  of  the 
day  but  which  would  seem  the  key  to  the  ex- 
planation of  a  large  number  of  cases.  Read- 
ing with  this  theory  in  mind,  it  has  often 
seemed  that  an  author  must  have  had  the  idea 
in  view  but  not  quite  clearly  enough  to  state 


4  PREFACE 

it.  The  chapter  on  "Hypertonia  Vasorum 
Idiopathica''  is  a  discussion  of  the  cHnical  ap- 
pHcation  of  the  theory  to  an  important  class  of 
cases.  The  title  of  the  book  has  been  slightly 
changed,  because  it  was  found  that  "Blood- 
Pressure"  alone  conveyed  the  idea  only  of 
laboratory  physiology  while  in  fact  the  book 
was  taken  up  with  the  consideration  of  cases 
that  are  popularly  called  "heart  disease." 

The  author  has  been  much  gratified  by  the 
attention  given  to  his  classification  of  disorders 
of  blood-pressure  and  by  the  frequent  reference 
by  writers  on  blood-pressure  to  the  condition 
described  by  him  in  a  paper  reprinted  on  pages 
87-90  describing  "Constitutional  Low  Arterial 

Tension.'* 

L.  F.  B. 

No.~54  West  55th  Street 

New  York  , 


PREFACE 

The  publication  of  a  treatise  on  blood-press- 
ure at  a  time  when  so  much  has  been  learned, 
and  so  many  books  are  appearing  on  the  sub- 
ject, demands  a  note  of  explanation. 

My  excuse  is  that  for  the  past  fifteen  years, 
indeed,  ever  since  as  an  hospital  interne  I  first 
came  in  contact  with  patients  suffering  from 
serious  disease  in  which  the  circulation  was 
involved,  the  question  of  the  vital  relations  of 
the  physics  of  the  circulation  has  been  one  of 
the  most  interesting  problems  that  has  con- 
stantly presented  itself  in  the  domain  of  clinical 
medicine.  During  this  time  the  care  of  pa- 
tients suffering  from  those  diseases  and  condi- 
tions in  which  the  fight  for  life  was  a  contest 
with  progressive  circulatory  failure,  has  formed 
a  serious  part  of  my  work. 


a  PREFACE 

It  IS  a  fact  that  is  constantly  appearing  in  the 
hterature  of  the  day,  that  circulatory  disease, 
as  represented  in  statistics  of  disease  of  the 
heart  and  disease  of  the  kidneys,  is  relatively 
more  frequent  than  formerly.  It  is  undoubtedly 
true  that  under  the  strain  of  modern  life,  many 
other  causes  of  disease  having  been  eliminated, 
disorders  of  the  circulation  dependent  upon 
altered  blood-pressure  have  become  very  im- 
portant. 

Just  as  tuberculosis  has  for  its  victims  the 
most  attractive  of  the  youth  of  the  land,  so 
high  arterial  tension  claims  the  best  and  most 
successful  of  those  past  middle  life  who  have 
borne  the  weight  of  the  strenuous  demands  of 
a  modern  career.  Much  attention  is  now  being 
directed  to  tuberculosis  because  its  cause  and 
progress  have  become  a  matter  of  public  knowl- 
edge. The  victims  of  circulatory  disease,  how- 
ever, still  too  often  go  for  months  and  years 
without  intelligent  treatment  because  no  one 
has  pointed  out  to  them  the  danger  signals  and 


PREFACE  7 

the  signboards  which  point  to  the  destruction 
to  which  they  are  tending. 

Admirable  as  is  the  work  of  the  rescue  of 
the  young,  who  may  or  may  not  become  citi- 
zens of  marked  usefulness,  how  much  more 
important  to  the  community  is  it  if  some  years 
can  be  added  to  the  career  of  the  mature  and 
trained  worker. 

The  subject  of  the  mechanical  measure- 
ment of  the  actual  pressure  in  the  vessels  has 
not  been  considered,  as  that  is  so  well  discussed 
in  other  works,  and  it  was  here  wished  to 
emphasize  the  clinical  relations  of  blood-press- 
ure as  interpreted  in  the  light  of  clinical 
experience.  There  is  an  over-respect  in  these 
days  for  so-called  scientific  zvork,  wrongly 
limiting  the  term  to  that  which  is  in  some 
way  connected  with  a  laboratory  and  apparatus. 
This  is  a  narrowness  of  recent  times.  There 
are  many  sciences  besides  mathematics,  ex- 
perimental biology,  and  chemistry,  and  if 
clinical   workers   yield   the  field   of   medicine 


8  PREFACE 

entirely  to  the  so-called  research  workers  and 
the  laboratory  men,  there  is  certain  to  be  a 
halt  in  the  progress  of  the  art  of  medicine  as  it 
bears  upon  the  wise  management  of  the  in- 
dividual during  the  course  of  his  life. 

These  are  the  reasons  for  the  publication  of 
the  conclusions  which  are  the  result  of  clinical 
work  upon  a  subject  which  is  being  well  con- 
sidered from  a  mechanical  and  laboratory  point 

of  view. 

L.  F.  B. 


CONTENTS 

I,     ALfERATIONS    OF    PRESSURE    IN    THE    BLOOD- 
VESSELS   13 

Importance  of  a  proper  relation  be- 
tween pressure  in  the  arteries,  resist- 
ance in  the  arterioles,  and  pressure  in 
the  veins;  physiologic  alterations;  the 
error  of  comparing  the  circulation  in 
the  body  to  the  passage  of  water 
through  pipes ;  the  arterial  system  as  a 
reservoir ;  importance  of  the  considera- 
tion of  the  evolution  of  the  circula- 
tion; the  author's  classification  of  cases 
of  circulatory  disease. 

II.  Primary  Low-Pressure  Cases  ...  22 
Similar  symptoms  often  produced  by 
anemia  and  congestion;  importance  of 
a  proper  movement  of  the  blood ;  valvu- 
lar disease  as  a  cause  of  low  arterial 
tension;  weakness  and  strain  of  the 
heart-muscle  as  a  cause  of  low  arterial 
tension;  prostration  of  the  circulation 
as  a  cause. 

III.    The     Management    of    Primary    Low- 

Pressure  Cases 27 

Treatment   dependent  upon  the  cause 
of  the  condition;  importance  of  iron, 
9 


10  CONTENTS 

arsenic,  liypernutrition,  and  exercise; 
management  of  valvular  cases  in  their 
early  stage;  use  of  iodid  of  soda;  im- 
portance of  the  vitalizing  effect  of  diet 
and  climate. 

IV.    High- Pressure  Cases  .       .       .       ...     32 

Defined  as  cases  in  which  there  is 
undue  resistance  in  the  circulatory  path 
of  the  blood;  term  not  confined  to 
cases  in  which  high-pressure  is  always 
actually  present ;  high-pressure  cases 
not  converted  into  low-pressure  cases, 
but  into  secondary  low-pressure  cases; 
management  of  high-pressure  cases  one 
of  the  most  important  problems  of 
modern  times;  early  indications  of  this 
condition  often  referred  to  the  brain, 
heart,  digestive    and  other  organs. 

V.    The     Management     of     High-Pressure 

Cases 42 

The  removal  of  the  exciting  cause; 
alcohol  not  always  contraindicated ; 
hydrotherapeutics  discussed;  Nauheim 
treatment;  health  resorts;  importance 
of  vacations  and  the  cultivation  of  the 
capacity  for  the  enjoyment  of  them; 
the  effect  of  temperament  on  the  prog- 
ress of  high-pressure  cases;  the  drug 
treatment  of  high  arterial  tension  not 
altogether  satisfactory;  dangers  to  be 
anticipated. 


CONTENTS  11 

VI.  Some  Obscure  Symptoms  of  Circulatory 
Disorder,  with  a  Consideration  of 
Their  Significance  .  .  .  .  .55 
Head  noises  in  elderly  people;  slight 
attacks  simulating  paralysis;  pain  In 
various  parts  of  the  body;  how  dis- 
tinguished from  other  pains;  conges- 
tion of  the  liver;  chronic  congestion  of 
the  lungs;  mania;  change  in  disposi- 
tion; convulsions;  the  relation  between 
neurasthenia  and  circulatory  disturb- 
ances. 

VII.    The    Management   of    Secondary    Low- 
Pressure  Cases 62 

The  element  of  constitutional  treat- 
ment most  important;  the  necessity 
for  a  closer  study  of  the  therapeutics 
of  these  cases;  the  effect  of  exercise. 

VIII.  General  Considerations  .  .  *  .68 
The  importance  of  treatment  In  the 
early  stages  of  arterial  degeneration; 
the  relation  of  nature's  provision  for  , 
heart  stimulation  and  control  to  the 
use  of  cardiac  drugs  In  acute  disease; 
the  Importance  of  considering  the  ele- 
ment of  vasomotor  instability  in' esti- 
mating the  significance  of  irregularities 
of  cardiac  rhythm;  discussion  of  the 
author's  views  by  Dr.  Albert  Abrams; 
constitutional  low  arterial  tension; 
prostration  of  the  circulation. 


12  CONTENTS 

IX.  The  Estimation  of  Blood-Pressure  and 
THE  Use  of  the  Nitrites  for  Its  Modi- 
fication  95 

Observation  of  the  pulse  a  matter  in 
which  great  skill  exists  not  to  be  entirely 
supplanted  by  instrumental  determina- 
tions. 

X.    The     Blood  -  Vessel    Tone  -  Maintaining 

Function  of  the  Brain 112 

The  vital  importance  of  the  tonus  of  the 
blood-vessels  to  life;  the  great  capacity 
of  the  dilated  blood-vessels;  the  central 
nervous  control  of  vessel  tonus  in  the 
higher  animals;  the  existence  of  a  tone- 
maintaining  function  in  the  human  brain 
analogous  to  a  similar  function  affecting 
the  voluntary  muscles;  the  relation  of 
this  function  to  the  vaso-motor  center 
in  the  medulla;  its  importance  in  clinical 
medicine. 

XI.  Hypertonia  Vasorum  Idiopathica  .  -.-  :.-  116 
A  disease  not  formerly  recognized  as 
having  an  independent  existence;  it 
attacks  the  most  useful  members  of 
society;  description  of  a  typical  case;  it 
may  result  in  apoplexy,  sudden  heart 
failure,  or  Bright's  disease;  medical 
treatment  very  important  and  drugs  of 
great  yalue. 


HEART     DISEASE 

AND 

BLOOD-PRESSURE 

4. 

CHAPTER  I 

ALTERATIONS     OF     PRESSURE    IN    THE    BLOOD- 
VESSELS 

Presupposing  a  knowledge  on  the  part  of 
the  reader  of  the  systematized  facts  concerning 
disease  of  the  heart  and  blood-vessels,  and  some 
actual  experience  in  the  treatment  and  care  of 
patients,  we  approach  the  subject  of  disorders 
of  the  circulation  from  the  viewpoint  of  the  con- 
sulting room  and  the  hospital  ward,  rather 
than  from  that  of  the  library,  the  pathologic 
laboratory,  and  the  classroom. 

We  find  immediately  that  we  have  to  deal 
for  the  most  part  with  slowly  developing  or 
long-established  conditions.  The  study  of 
acute  disease  is  of  great  importance,  particu- 
larly to  the  beginner  in  practice  who  desires  to 
hang  an  item  of  experience  upon  each  peg  of 
recently  acquired   knowledge,   but   in   actual 

13 


14  BLOOD-PRESSURE 

practice,  on  the  principle  of  the  greatest  good 
to  the  greatest  number,  the  attentive  study  of 
chronic  disease  is  at  least  equally  necessary. 

Alteration  of  pressure  of  the  blood  in  the 
vessels  constitutes  the  most  striking  disorder 
of  the  general  circulation,  and  upon  a  study  of 
its  causes,  effects,  and  control,  will  be  built 
this  entire  consideration  of  the  subject.  In- 
deed, the  whole  mechanism  of  the  circulation 
has  to  do  with  the  maintenance  of  high-press- 
ure or  low-pressure  in  one  part  or  another  of 
the  vascular  system  as  may  be  demanded. 

It  is  easy  to  see  that  the  maintenance  of  the 
circulation  is  not  a  question  of  the  degree  of 
tension  in  any  part  of  the  circulatory  system, 
but  of  a  proper  relation  in  tension  between 
pressure  in  the  arteries,  where  the  blood  is 
stored,  and  the  points  at  which  it  is  needed.  It 
is  usual,  however,  to  study  the  question  from 
the  standpoint  of  the  arteries.  In  most  cases 
it  is  only  late  in  circulatory  disease  that  venous 
pressure  becomes  of  importance.  The  freedom 
of  passage  between  the  arteries  and  veins 
through  the  arterioles  and  capillaries  is  of  ex- 
treme importance. 


PRESSURE  IN  THE  BLOOD-VESSELS         15 

,  In  health  the  physiologic  relations  of  blood- 
pressure  are  instructive.  The  effect  of  muscu- 
lar exercise  on  blood-pressure  is  at  first  to  raise 
arterial  pressure,  but  finally  after  the  exercise 
has  been  continued  for  some  time,  the  pressure 
falls  again  to  normal.  The  same  is  true  in 
regard  to  the  effect  of  mental  effort. 

During  the  existence  of  this  increase  of  ar- 
terial pressure  due  to  exercise,  there  is  a  large 
amount  of  blood  in  the  arteries.  This  is  ob- 
tained from  the  large  veins  in  the  abdomen, 
which  act  as  a  source  of  supply  from  which,  in 
health,  blood  can  be  drawn  to  flush  any  part  of 
the  arterial  system.  This  tide  of  blood  between 
the  digestive  organs  and  the  systemic  area  is 
illustrated  in  many  ways.  Thus,  the  coldness 
after  eating  indicates  that  the  tide  has  set  to- 
ward the  digestive  organs.  The  indigestion 
following  exercise  after  eating,  and  even  more 
markedly  the  indigestion  following  strong 
emotion  after  a  meal,  shows  that  the  tide  has 
set  the  other  way.  The  lethargy  and  mental 
inactivity  of  those  who  habitually  overeat,  and 
the  tendency  to  indigestion  of  mental  workers, 
indicate  the  same  thing.    The  relation  between 


16  BLOOD-PRESSURE 

the  circulation  in  the  abdomen  and  the  circula- 
tion in  the  brain  is  an  intimate  one.  The 
proverbially  good  mental  condition  in  patients 
suffering  from  acute  peritonitis  may  very  well 
be  due  to  the  spasm  of  all  the  abdominal 
muscles  that  prevents  the  accumulation  of 
large  quantities  of  blood  in  this  part  of  the 
body. 

The  impression  of  the  circulation  obtained 
by  one's  early  study  of  physiology  is  erroneous. 
It  resembles  too  closely  the  idea  of  a  series 
of  closed  pipes,  as  in  the  plumbing  of  a 
house,  the  water  entering  at  a  large  pipe, 
going  through  a  system  of  smaller  pipes,  and 
after  having  been  used  in  certain  fairly  defi- 
nite receptacles  to  be  collected  by  a  similar  set 
of  pipes  which  convey  it  to  a  common  outlet. 
Of  course,  in  a  house  the  circle  is  not  complete, 
as  the  water  does  not  again  re-enter.  In  gen- 
eral, however,  that  is  the  conception  of  the 
arrangement  that  is  obtained  by  the  average 
teaching  of  physiology.  ^ 

The  facts,  however,  are  very  different  in  the 
human  body.  The  arterial  system  is  really  a 
reservoir  of  blood  in  which  the  area  of  a  cross 


WESSURE  m  THE  BLOOD-VESSELS        17 

s.ection  of  the  combined  vessels  very  rapidly 
increases  from  the  heart  outward.  In  this 
series  of  passages  the  blood  is  contained  and 
held  under  pressure  by  a  muscular  envelope. 
From  this  reservoir  the  blood  escapes  for  use, 
through  the  arterioles  and  capillaries,  and  the 
office  of  the  heart  is  to  pump  into  this  reser- 
voir sufficient  blood  to  maintain  the  pressure 
depleted  by  the  blood  used  by  the  capillaries. 
This  naturally  creates  a  flow  of  blood  from  the 
heart  toward  the  periphery,  but  the  immediate 
use  of  the  heart  is  to  maintain  this  arterial 
pressure. 

This  is  well  shown  by  the  fact  that  the 
actual  amount  of  blood  propelled  by  the  heart 
varies  greatly,  according  to  the  demand  for 
fresh  blood  on  the  part  of  the  body.  During 
exercise,  when  the  peripheral  vessels  are  open, 
and  there  is  a  drain  on  the  arterial  system,  the 
heart  works  harder  to  supply  the  deficiency. 
Thus  the  arrangement  and  movement  of  blood 
in  the  body  are  seen  to  be  more  like  a  system 
of  irrigation  than  of  circulation,  there  being  a 
reservoir  with  numerous  branches  from  which 
the  irrigating  fluid  is  distributed,  and  a  system 


18  BLOOD-PRESSURE 

of  conduits  by  which  it  is  collected  to  be  again 
transferred  to  the  storage  place. 

The  idea  of  the  office  of  the  veins  as  a  store- 
house of  blood  is  a  very  old  one,  and  one  which 
has  had  much  influence  upon  therapeutics. 
The  consideration  of  the  arterial  system  as  a 
similar  reservoir  in  which  suitable  pressure  is 
maintained  by  the  muscular  elements  which  go 
to  make  it  up,  seems  to  have  been  overlooked. 
The  truth  of  the  fact  that  the  arteries  form  a 
reservoir  rather  than  mere  conduits  is  shown 
by  the  fact  that  arterial  pressure  is  practically 
uniform  throughout  the  arterial  system.  This 
means  that  the  blood  moves  with  the  utmost 
freedom  throughout  the  arteries,  and  that  the 
movement  of  the  blood  is  controlled,  not  by 
pressure  from  behind,  but  by  the  escape  of 
blood  from  in  front. 

The  arterial  system  is  thus  like  a  reservoir 
analogous  to  the  tubular  boiler  of  some  types 
of  engines.  It  is  a  hollow  ramifying  organ 
containing  a  vital  fluid,  the  capillaries  being  the 
ducts.  Whenever  there  is  a  demand  for  this 
vital  fluid  in  any  part  of  the  system,  the  mus- 
cular  covering   of   the   organ    contracts,    the 


PRESSURE  m  THE  BLOOD-VESSELS        19 

arterioles  which  lead  to  the  proper  capillaries 
dilate,  and  the  demand  is  supplied.  The  de- 
mand upon  this  organ  for  the  vital  fluid  is  so 
great  that  a  special  mechanism,  represented  by 
the  heart,  conducts  the  vital  fluid  from  the 
places  where  it  is  manufactured,  and  the  lungs 
where  it  is  purified,  to  the  high-pressure  re- 
ceptacle from  which  it  is  used. 

This  conception  of  the  arterial  system  as  a 
high-pressure  receptacle  for  the  blood,  is  well 
borne  out  by  a  study  of  the  evolution  of  the 
circulation  in  the  lower  forms  of  life,  where 
there  are  first  found  small  interstices  in  the 
tissues  through  which  the  blood  ebbs  and  flows 
in  an  irregular  manner.  As  we  ascend  the 
scale  the  blood  is  found  in  more  definite  re- 
ceptacles until  finally  we  reach  the  complex 
arrangement  found  in  man. 

The  action  of  the  vascular  system  is,  on  a 
large  scale,  not  different  in  principle  from  that 
of  a  secretory  gland  adapted  to  the  unusual 
demand  for  its  contained  fluid. 

The  so-called  circulation  of  the  blood  was 
discovered  very  late  in  the  history  of  man,  and 
students  have  become  so  fascinated  with  the 


20  BLOOD-PRESSURE 

mechanical  beauty  of  the  whole  arrangement, 
that  they  have  allowed  the  mechanical  idea  to 
outweigh  the  realization  of  a  living  organism. 
It  is  the  old  truth  of  the  pendulum  which  has 
swung  too  far  when  once  started  by  Harvey. 
We  need  to  return  a  little  to  the  earlier  con- 
ception, which  considered  more  the  function  of 
the  blood  in  particular  parts  of  the  body  than 
its  circulation. 

In  all  studies  of  blood-pressure  it  must  be 
remembered  that  the  blood  is  subject  to  the 
laws  of  hydrostatics,  and  that  the  force  of 
gravity  m.ust  be  discounted. 

There  are  two  great  groups  of  cases  which 
may  well  be  called  low-tension  cases  and  high- 
tension  cases,  and  a  third  group  of  secondary 
low-tension  in  which  there  has  been  a  preced- 
ing high-tension. 

The  low-tension  cases  are  all  those  in  which 
inflammation  or  degeneration  of  the  heart 
muscle  itself,  its  envelopes  or  its  valves,  has 
primarily  interfered  with  the  blood-propelling 
function  of  the  heart. 

The  high-tension  cases  are  all  those  in  which 
disorder  of  the  arterioles,  due  to  toxemia  or 


PRESSURE  m  THE  BLOOD-VESSELS         2l 

other  causes,  has  brought  about  an  unreason- 
able demand  on  the  part  of  the  system  for  a 
high-tension  in  the  arterial  reservoir  to  deter- 
mine the,  proper  supply  of  blood  to  the  tissues. 

It  is  particularly  important  from  the  point 
of  view  of  practical  physicians  to  distinguish 
between  the  two  great  groups  of  circulatory 
disease,  both  in  their  early  and  in  their  late  de- 
velopment, because  there  is  an  essential  differ- 
ence in  their  management. 

Low  arterial  tension  as  a  terminal  stage  of 
high  arterial  tension,  must,  of  course,  be  con- 
sidered in  the  light  of  its  development,  but  is 
of  so  great  importance  that  we  have  studied  it 
by  itself. 


CHAPTER  II 

PRIMARY    LOW-PRESSURE    CASES 

Disorders  of  the  general  circulation  are 
generally  first  recognized  when  some  particular 
portion  of  the  body  becomes  the  seat  of  a 
marked  congestion  or  anemia.  It  is  under 
these  circumstances  that  symptoms  arise. 

Anemia  and  congestion  often  produce  symp- 
toms that  are  strikingly  similar.  Delirium  may 
be  the  result  of  congestion  of  the  brain,  but  it 
may  likewise  result  from  anemia.  Dyspnea 
may  be  an  accompaniment  of  congestion  of  the 
lungs,  but  a  deficient  blood  supply  is  its  most 
common  cause.  Acute  congestion  of  the  kid- 
neys causes  suppression  of  urine,  while  dimin- 
ished blood  supply  causes  deficiency  of  secre- 
tion. 

The  effect  upon  an  organ  is  a  matter  of  the 

proper  supply  of  fresh  blood,  not  merely  of  a 

greater  or  less  amount  of  blood  being  in  the 

32 


PRIMARY  LOW-PRESSURE  CASES  23 

vessels  of  the  organ.  This  explains  beautifully 
the  effect  of  local  therapeutics,  such  as  the  re- 
moval of  a  small  quantity  of  blood,  or  the  insti- 
tution of  some  form  of  counter-irritation,  the 
result  of  which  is  to  start  a  stagnant  local  cir- 
culation. There  is,  however,  little  gain  from 
the  treatment  of  local  congestion  or  anemia 
without  attention  to  the  general  circulation  in 
cases  where  the  cause  is  general.  Hence  the 
extreme  importance  of  recognizing  which  cases 
are  of  purely  local  origin,  and  which  have  their 
origin  from  the  general  circulation. 

In  this  study  of  the  circulation  we  will  not 
include  an  extensive  consideration  of  the  in- 
flammatory diseases  of  the  heart,  but  will  con- 
centrate our  attention  upon  those  conditions 
which  we  are  most  often  called  upon  to  treat, 
and  leave  to  the  more  comprehensive  treatises 
the  systematic  consideration  of  the  morphology 
of  heart  lesions  and  the  discussion  of  physical 
signs. 

During  the  acute  stage  of  valvular  disease, 
in  the  large  majority  of  cases,  circulatory  fail- 
ure does  not  become  a  matter  of  special  anx- 
iety.   Low  arterial  tension  usually  shows  itself 


U  BLOOD-PRESStJR:fi 

when  the  patient  resumes  his  ordinary  occu- 
pation. 

The  symptoms  are  practically  the  same  for 
all  forms  of  valvular  lesions,  although  dif- 
ferent in  degree.  Indeed,  it  is  more  often  an 
academic  than  a  practical  question  to  decide 
which  valves  are  at  fault.  Much  more  im- 
portant is  the  question  whether  the  defect  has 
been  properly  compensated,  and  whether  this 
compensation  can  be  maintained.  In  general, 
however,  it  may  be  considered  that  in  aortic 
disease  the  defective  circulation  is  more  strik- 
ingly due  to  an  insufficient  supply  of  blood  in 
the  arteries,  and  in  mitral  disease  to  an  in- 
creased pressure  in  the  veins,  both  resulting  in  a 
diminution  of  the  difference  in  pressure  in  the 
arteries  and  veins,  upon  which  the  proper 
passage  of  the  blood  through  the  tissues  de- 
pends. 

The  belief,  so  firmly  held  by  many,  that  car- 
diac disease  is  usually  confined  to  the  left  side 
of  the  heart  is  not  borne  out  in  practice.  The 
most  serious  and  fatal  disorders  involve  the 
right  side  of  the  heart.  This  belief  that  the 
left  side  of  the  heart  was  almost  the  sole  suf- 


PRIMARY  LOW-PRESSURE  CASES  25 

ferer  from  heart  disease,  was  founded  upon  an 
old  pathology  which  regarded  chiefly  the  val- 
vular deformities. 

It  is  true  that  inflammation  and  distortion  of 
the  valves  is  almost  entirely  confined  to  the 
left  side  of  the  heart,  but  it  is  likewise  true 
that  both  sides  sufl:'er  equally  in  the  incom- 
petencies of  the  valves  that  come  from  strain 
or  weakness  of  the  heart -muscle  as  seen  in  very 
many  cases  of  disorder  of  the  circulation. 

The  left  side  of  the  heart  can  be  markedly 
deficient  in  mechanical  detail  or  physical  struc- 
ture, and  the  patient  may  get  along  fairly  well 
until  dilatation  involving  the  right  side  of  the 
heart  takes  place,  with  tricuspid  regurgitation 
and  its  resulting  venous  engorgement. 

It  is  necessary  to  remember  that  low  arterial 
pressure  is  only  to  be  regarded  as  pathologic 
when  it  is  so  little  above  venous  pressure  that 
the  tissues  and  organs  are  not  properly  sup- 
plied with  blood.  There  are  instances  where 
the  heart  is  perfectly  able  and  willing  to  pro- 
duce more  arterial  pressure,  but  the  peripheral 
circulation  is  so  relaxed  that  it  is  not  needed. 

We    get    true    low-pressure    cases    when 


26  BLOOD-PRESSURE 

the  pressure-producing  mechanism  has  failed. 
These  are  primary  when  there  has  not  been  a 
previous  over-demand  for  pressure. 

Low  blood-pressure  due  to  general  prostra- 
tion is  not  to  be  regarded  as  a  disorder  of  the 
circulation  except  in  so  far  as  the  circulation 
fails  to  respond  to  demands  made  upon  it. 
Thus  in  shock  it  is  the  nervous  system  that  is 
at  fault,  not  the  circulatory  apparatus. 


CHAPTER  III 

THE    MANAGEMENT    OF    PRIMARY    LOW- 
PRESSURE    CASES 

The  indications  for  treatment  in  disorder 
of  the  circulation  characterized  by  deficiency 
in  pressure  in  the  blood-vessels  which  is  pri- 
mary in  that  it  has  not  been  preceded  by  high 
arterial  tension,  are  simple,  though  the  elabora- 
tion of  the  management  of  each  case  will  tax 
the  judgment  and  ingenuity  of  the  physician. 

When  there  is  no  defect  in  the  valves  and  no 
tendency  to  obstruction  in  the  arteries,  the  con- 
dition is  usually  a  weakness  of  the  heart,  and 
much  may  be  accomplished  by  iron,  arsenic, 
and  hypernutrition,  by  increasing  the  number 
of  meals,  and  by  outdoor  exercise. 

When  low-pressure  is  due  to  valvular  dis- 
ease we  must  consider  the  care  of  the  heart 
before  the  establishment  of  complete  compensa- 
tion, during  compensation,  and  in  cases  of 
broken  compensation. 

87 


28  BLOOD-PRESSURE 

In  the  early  days  of  a  newly  acquired  val- 
vular lesion,  prolonged  rest  in  bed  with  the 
very  gradual  resumption  of  a  more  active  life, 
will  enable  both  the  heart  and  the  body  in  gen- 
eral to  adapt  themselves  to  the  new  conditions. 
Of  necessity  there  must  be  a  compensatory 
hypertrophy,  but  it  is  not  to  the  advantage  of 
the  patient  that  the  hypertrophy  be  excessive, 
hence  the  desirability  of  such  gradual  resump- 
tion of  active  work.  Until  subjective  symp- 
toms and  objective  signs  of  defective  circula- 
tion have  disappeared,  the  patient  must  be  re- 
stricted to  a  very  quiet  existence. 

The  use  of  drugs  at  this  time  is  usually 
inadvisable,  yet  in  cases  of  long-delayed  com- 
pensation digitalis  may  be  used. 

When  compensation  is  established  and 
proper  pressure  in  the  arteries  maintained, 
these  cases  may  still  be  classed  in  the  category 
of  low  arterial  tension  because  of  their  tend- 
ency to  this  condition,  just  as  we  consider 
cases  of  Bright's  disease  as  being  high-press- 
ure cases  even  when  the  condition  is  not  actu- 
ally present  at  the  time. 

During  the  stage  of  compensation,   which 


PEIMARY  LOW-PBESSURE  CASES  29 

may  be  of  long  duration,  the  patient  should 
lead  a  well-regulated  existence — physical  over- 
exertion, mental  over-anxiety,  and  dissipation 
of  all  kinds  must  be  avoided.  Not  only  is  a 
quiet  life  necessary  when  conscious  symptoms 
are  being  caused,  but  also  on  account  of  the 
tendency,  without  conscious  symptoms,  to  the 
production  of  excessive  hypertrophy,  leading 
in  the  end  to  degeneration.  The  occasional 
use,  during  the  stage  of  compensation,  of  the 
iodid  of  soda  as  a  means  of  preventing  degen- 
eration of  the  hypertrophied  heart,  is  a  useful 
procedure  even  when  no  other  drug  therapy 
seems  advisable. 

The  treatment  of  low-tension  resulting  from 
ruptured  compensation  in  a  valvular  case  free 
from  the  taint  of  arterial  resistance,  often  con- 
sists principally  in  rest  in  bed  with  particular 
care  of  the  alimentary  canal,  no  drugs  being 
used  at  all.  If  the  attack  be  more  severe,  with 
congestion  of  the  kidneys  and  edema  of  the  ex- 
tremities, digitalis  should  be  used  for  a  time. 

It  is  interesting  to  note  that  when  a  system 
of  treatment  has  proved  applicable  to  a  particu- 
lar form  of  disease,  very  soon  its  application 


30  BLOOD-PRESSURE 

becomes  extended  to  other  diseases.  The  cure 
of  tuberculosis  is  acknowedged  to  be  a  matter 
of  the  re-estabhshment  of  certain  forces  in 
the  physical  economy,  the  breaking  down  of 
which  renders  the  patient  susceptible  to  the 
disease. 

In  the  progress  of  cardiac  disease  there  are 
many  elements  that  are  not  unlike  the  advance 
of  tuberculosis.  The  term  "cardiac  ca- 
chexia "  has  been  applied  to  a  form  of  this 
condition  accompanied  by  congestion,  but  it 
might  well  be  extended  to  include  the  deterio- 
ration of  fiber  which  leads  to  failure  of  the 
circulatory  apparatus.  In  tuberculosis  the  con- 
nection between  the  cachexia  and  the  disease 
is  so  evident  that  its  hygienic  management 
needs  no  advocate.  It  is  equally  true  that  the 
progress  of  circulatory  disease  is  often  depend- 
ent upon  nutritional  causes,  and  that  the  hy- 
giene of  tuberculosis  in  its  demand  for  fresh  air 
is  equally  important  to  the  cardiac  patient. 

The  vitalizing  effect  of  fresh  air  in  these 
cases  will  more  than  counterbalance  the  dan- 
gers of  catching  cold,  although  care  is  neces- 
sary when  inflammation  or  congestion  of  the 


PRIMARY  LOW-PRESSURE  CASES  31 

kidneys  is  present.  The  patient  can  be  trained 
to  sleep  with  open  windows. 

Concerning  warm  bathing,  it  seems  to  be  a 
fact  that  there  is  much  less  danger  of  taking 
cold  than  was  formerly  supposed.  This  fear 
is  a  tradition  handed  down  from  an  age  when 
bathtubs  were  more  of  a  curiosity  than  they 
are  in  modern  times.  Our  ancestors  considered 
the  taking  of  a  hot  bath  before  going  out,  a 
serious  risk.  Now,  this  is  something  that  is 
done  by  thousands  of  people  every  day  without 
bad  results.  It  seems  that  the  risk  of  exposing 
the  body  to  changes  of  temperature  after  the 
bath  rapidly  diminishes  when  the  patient  has 
become  accustomed  to  regular  bathing. 

Low-pressure  due  to  degeneration  of  the 
heart-muscle  which  has  not  been  preceded  by 
hypertrophy  is  not  at  all  common  except  in  con- 
nection with  acute  or  chronic  general  disease. 
The  treatment  in  these  cases  is  that  of  the  gen- 
eral disease.  But  little  is  accomplished  by  meas- 
ures directly  influencing  the  circulation.  The 
same  is  true  of  the  heart  overloaded  with  fat. 
Treatment  must  be  hygienic,  though  the  defec- 
tive heart-muscle  demands  special  precautions. 


CHAPTER  IV 

HIGH-PRESSURE   CASES 

By  high-pressure  cases  in  contradistinction 
to  low-pressure  cases  are  meant  all  those  cir- 
culatory disorders  which  are  characterized  by 
undue  resistance  in  the  circulatory  path  of  the 
blood.  It  is  not  necessary,  for  cases  to  be 
classed  in  this  category,  that  actual  high-press- 
ure should  always  be  present  in  the  blood- 
vessels. It  is  enough  that  there  is  a  tendency 
toward  the  necessity  for  abnormal  high-press- 
ure for  the  proper  circulation  of  the  blood. 

High-pressure  cases  comprise  all  instances 
in  which  degenerative  disease  of  the  blood- 
vessels or  kidneys,  or  toxemia  causing  dis- 
ordered action  of  the  same,  and  resulting  in 
high  arterial  tension,  precedes  or  goes  hand  in 
hand  with  the  development  of  cardiac  disease. 

Low-pressure  cases  occasionally  become 
high-pressure  cases,  as  when  valvular  disease 

33 


HIGH-PRESS'URE  CASES  33 

of  the  heart  causes  secondary  Bright's  disease. 
High-pressure  cases,  however,  are  not  converted 
into  low-pressure  cases,  as  a  sharp  distinction 
must  be  drawn  between  primary  and  secondary 
low  arterial  tension. 

The  management  of  high-pressure  cases, 
which  includes  a  large  proportion  of  the  slowly 
developed  diseases  incident  to  the  overwork  and 
luxury  of  modern  times,  is  relatively  more  im- 
portant than  that  of  the  low-pressure  cases.  It 
is  particularly  important  to  detect  the  earliest 
development  of  a  tendency  to  high  arterial 
tension  because  at  this  time  it  is  more  amenable 
to  treatment. 

Disorder  of  the  general  circulation  is  the 
great  factor  which  has  to  do  with  the  limita- 
tion of  life  in  all  persons  who  escape  those 
causes  of  death  which  are  more  or  less  acci- 
dental, so  when  local  disease  is  eliminated, 
duration  of  life  depends  upon  the  integrity  of 
the  heart  and  blood-vessels. 

As  implied  above,  in  this  class  of  cases  the 
heart,  blood-vessels  and  kidneys  go  hand  in 
hand,  and  serious  disease  of  one  is  not  found 
without  involvement  of  the  others.    Hence  the 


34  BLOOD-PRESSURE 

term  ''  chronic  Bright's  disease  "  is  frequently 
used  in  speaking  of  these  cases.  The  fact  that 
this  law  of  the  co-relation  of  the  heart,  blood- 
vessels and  kidneys  has  been  overlooked  in 
the  past,  has  led  to  much  misconception,  not 
only  as  to  disease  of  the  kidneys,  but  also  disease 
of  the  blood-vessels  and  heart.  When  they  are 
studied  together  it  is  found  that  often  the  ear- 
liest indication  of  disease  of  the  one  is  found 
in  disorder  of  the  other.  Chronic  Bright's 
disease  is  not  essentially  a  disease  of  the  kid- 
neys, although  in  the  final  catastrophe  these 
organs  are  often  chiefly  at  fault.  Primarily 
it  is  a  disease  of  the  circulation  in  which  the 
brain  and  kidneys,  acting  as  it  were  as  end- 
organs,  first  manifest  symptoms. 

A  case  which  had  been  under  observation 
for  five  years  ended  fatally  by  the  involve- 
ment of  the  circulation  of  the  brain,  produc- 
ing progressive  stupor  and  finally  coma,  par- 
alysis, and  death.  The  kidneys  at  the  time 
were  apparently  in  good  enough  condition  to 
have  functionated  fairly  well  for  a  much  longer 
time.  In  this  case  the  greatest  care  had  been 
exercised  in  protecting  the  kidneys  by  diet,  an 


filGH-PRESSURE  CASES  35 

even  temperature,  and  every  other  possible 
means,  thus  allowing  the  arterial  disease  an 
opportunity  for  its  complete  development. 
The  same  case,  if  less  carefully  guarded,  would 
have  progressed  by  repeated  attacks  of  uremia, 
to  a  death  by  the  development  of  anasarca  and 
exhaustion.  We  have,  then,  the  paradox  that 
a  person  may  die  from  Bright's  disease  with 
fairly  good  kidneys,  this  case  illustrating  the 
fact  that  the  brain  and  the  kidneys  are  both 
end-organs,  and  that  in  particular  cases  the 
brain  may  suffer  more  than  the  kidneys. 

This  point  is  important  in  considering  the 
early  symptoms  in  high-pressure  cases.  The 
kidneys  are  insensitive  organs,  rarely  giving 
rise  to  pain,  intermittent  in  their  manifesta- 
tions, and  entirely  removed  from  direct  ob- 
servation; for  this  reason  disorder  of  the 
kidneys  may  reach  a  grave  stage  before  it 
becomes  a  matter  of  consciousness.  On  the 
other  hand,  the  brain,  as  the  seat  of  conscious- 
ness, is  highly  sensitive  to  any  interference 
with  its  functions.  To  a  certain  extent  it  is 
also  capable  of  examination  through  the  ob- 
servation of  the  fundus  of  the  eye,  which  is  in 


36  BLOOD-PRESSURE 

close  relationship  to  the  brain.  It  may  be 
stated  that  the  brain  records  at  all  times,  in  a 
more  or  less  distinct  manner,  the  condition  of 
the  circulation,  and  a  careful  study  of  the 
symptom-complex  soon  reveals  which  dis- 
turbances of  the  circulation  indicate  organic 
disease  of  the  vessels  and  early  Bright's  dis- 
ease. Attention  and  observation  soon  make 
this  symptom-complex  of  extreme  signifi-' 
cance. 

Even  in  cases  in  which  chronic  Bright's  dis- 
ease follows  acute  nephritis,  the  establishment 
of  the  chronic  condition  is  characterized  by 
certain  detectable  vascular  changes.  In  cases 
of  acute  nephritis  one  watches  the  circulatory 
system  with  anxiety,  because,  when  changes  are 
established,  the  chance  of  complete  recovery  is 
diminished.  In  acute  Bright's  disease  the 
heart  is  temporarily  debilitated  so  that  there 
is  often  established  a  blowing  systolic  murmur 
at  the  apex,  and  the  profound  anemia  and  ner- 
vous phenomena  that  accompan}^  the  disease 
may  lead  to  other  functional  disturbances  of 
the  circulation.  These  must,  however,  be  dis- 
tinguished from  the  changes  that  take  place  in 


HIGH-PRESSURE  CASES  3V 

the  arteries  which  indicate  the  transition  from 
subacute  nephritis  to  the  chronic  general  con- 
dition. The  same  change  sometimes  indi- 
cates the  estabHshment  of  a  chronic  nephritis 
in  cases  of  valvular  disease  of  the  heart  that 
have  been  accompanied  by  prolonged  conges- 
tion of  the  kidneys. 

Though  it  is  hardly  to  be  supposed  that  car- 
diac hypertrophy  can  be  established  except  by 
some  cause  acting  for  a  considerable  period  of 
time,  still  it  is  often  the  earliest  detectable  sign 
of  chronic  nephritis.  Abnormal  arterial  ten- 
sion may  for  the  moment  be  absent,  either  on 
account  of  treatment  or  for  some  other  cause, 
but  when  physical  examination  shows  distinct 
cardiac  hypertrophy  we  suspect  at  once  a  high- 
pressure  case  of  circulatory  disease. 

It  is  probable  that  an  increased  flow  of  urine 
found  in  early  Bright's  disease  is  due  as  much 
to  increased  blood-pressure  as  to  any  definite 
change  in  the  kidneys.  Loomis  speaks  of  an 
increased  frequency  of  urination  as  an  early 
sign  of  Bright's  disease,  and  this  again  may 
well  be  accounted  for  by  increased  secretion 
due  to  increased  arterial  tension. 


38  BLOOD-PRESSURE 

Nose-bleed  is  another  possible  result  of  in- 
creased arterial  tension,  and  may,  therefore,  in- 
dicate the  beginning  of  Bright's  disease.  An- 
other accompaniment  of  increased  arterial  ten- 
sion is  headache,  due  apparently  to  increased 
vascular  tension  in  the  head. 

I  would  also  like  to  class  as  one  of  the  early 
disturbances  of  high-pressure  cases,  certain  at- 
tacks of  indigestion.  These  are  due  at  this 
early  stage  to  disturbances  of  circulation  in  the 
stomach,  and  are  not  to  be  confounded  with 
uremic  nausea. 

High-pressure  cases  more  often  develop  in 
an  atypical  than  in  a  typical  way,  and  even  in 
their  final  fatal  course  may  never  present  the 
symptoms  that  one  would  expect.  The  early 
symptoms  are  often  an  unhealthy  look,  loss  of 
strength,  and  such  disturbances  of  digestion  as 
may  be  referred  to  simple  weakness.  The 
urine  may  only  contain  albumin  at  rare  inter- 
vals, so  that  it  would  not  be  detected  by  any- 
thing save  systematic  observation. 

It  is  fair  to  say  that  the  early  signs  of  im- 
pending changes  in  the  blood-vessels  also 
mean  the  early  circulatory  changes  of  Bright's 


HIGH-PRESSURE  CASES  39 

disease.  The  first  signs  of  degeneration  are 
manifested  by  disorder  of  function.  The 
blood-vessels  act  as  tubes  to  convey  the  blood  to 
different  parts  of  the  body,  but  at  the  same 
time,  through  the  muscular  structure  of  their 
walls,  they  act  as  regulators  of  blood-pressure. 
This  pressure-regulating  function  is  an  ex- 
ceedingly complex  one  and  controls  the  de- 
termination of  blood  to  the  different  parts  of 
the  body  as  it  may  be  most  needed.  It  is  this 
regulating  function  which  first  suffers  when 
the  tendency  to  high-pressure  begins  to  show 
itself,  so  that  irregularity  of  tension  is  the 
most  important  early  circulatory  indication. 

We  have  traced  those  signs  and  symptoms 
in  the  circulation  which  precede,  for  a  long 
time,  the  establishment  of  that  condition  known 
as  chronic  Bright's  disease.  The  smaller  ar- 
teries are  attacked  earliest,  and  these  are  the 
first  to  show  disordered  function.  Increased 
arterial  tension,  or  a  tendency  to  it,  causes  ir- 
regularity of  blood-pressure,  and  is  early 
recognized  by  symptoms  indicating  irregulari- 
ties of  circulation  in  particular  parts  of  the 
brain.    This  irregularity  may  give  rise  to  tern- 


40  BLOOD-PRESSURE 

porary  unconsciousness,  slight  paralysis,  or 
simply  to  clumsiness  of  a  limb. 

The  typical  high-pressure  case  as  met 
with  in  practical  work,  is  usually  one  which 
has  gone  on  to  its  full  development  without  ob- 
servation or  treatment.  The  patient  presents 
himself  because  he  has  symptoms,  or  because 
ori  some  occasion  an  examination  has  revealed 
the  chemical  or  physical  signs  of  the  condi- 
tion. The  heart  is  found  hypertrophied,  the 
arterial  tension  high,  and  the  urine  increased. 
Careful  questioning  will  elicit  symptoms  of 
disorder  of  the  cerebral  circulation  as  indi- 
cated by  a  subjective  feeling  of  nervousness, 
headache,  insomnia,  or  attacks  of  dizziness,  or 
even  threatened  aphasia,  and  hemiplegia.  The 
hypertrophied  heart  is  compensatory,  having 
been  hypertrophied  in  order  to  meet  the  de- 
mand for  high  arterial  tension,  just  as  the 
heart  in  valvular  disease  is  hypertrophied  to 
meet  the  demand  for  normal  arterial  tension 
when  it  is  working  at  a  disadvantage. 

So  long  as  the  arterial  tension  is  maintained, 
the  patient  is  not  in  danger  in  the  direction  of 
the  circulation,  but  is,  of  course,  liable  to  ac- 


HIGH-PRESSURE  CASES  41 

cidents  due  to  injuries  to  the  nervous  system, 
or  a  sudden  failure  on  the  part  of  the  kidneys. 
The  circulatory  danger  arises  from  the  ex- 
hausting condition  under  which  it  is  carried  on 
and  the  inevitable  approach  of  the  time  when 
the  tension  can  no  longer  be  maintained,  hence 
the  vital  importance  of  seeking  out  and  re- 
lieving the  underlying  cause  of  this  high  ar- 
terial tension,  and  the  futility,  except  as  a 
temporary  expedient,  of  treating  the  symptom 
itself  as  the  primary  disease  by  the  prolonged 
administration  of  vaso-dilators. 


CHAPTER  V 

THE    MANAGEMENT    OF    HIGH-PRESSURE    CASES 

The  management  of  high-pressure  cases  is 
perhaps  the  most  important  topic  of  our  whole 
subject,  as  it  is  also  the  one  in  which  the  great- 
est advance  Thas  been  made  in  the  knowledge  of 
circulatory  disorders. 

The  causes  of  high-pressure  are  all  those 
circumstances  which  occasion  a  long-continued 
demand  for  hyperactivity  of  the  circulation, 
also  those  conditions  which  interfere  with  the 
proper  carrying  out  of  the  chemical  operations 
in  the  body,  whereby  there  remain  in  the 
circulation  incomplete  chemical  products. 
The  same  chemical  cause  may  arise  in  a  dif- 
ferent manner  through  an  interruption  of  the 
work  of  the  kidneys  whereby  toxic  substances 
are  retained  in  the  blood.  The  latter  two 
causes  fall  under  the  head  of  gout  and  Bright's 
disease.     Certain  toxins,  as  for  instance  those 

of  the  infectious  diseases,  probably  only  cause 

42 


MANAGEMENT  OF  HIGH-PRESSURE  CASES     43 

high-pressure  cases  through  primary  damage 
to  the  kidneys. 

The  first  principle  of  all  treatment  must  be 
the  removal,  as  far  as  possible,  of  the  causes  of 
the  condition,  hence  the  management  of  high- 
pressure  cases  must  begin  by  the  discovery  and 
removal  of  the  influence  v^hich  has  led  to  their 
development.  Thus,  a  man  v^ho  is  intemperate 
v^ith  regard  to  alcohol  must  be  cautioned 
against  its  use;  the  man  who  has  assumed  an 
unusual  burden  of  responsibility  in  life  must 
readjust  his  plans  so  as  to  lead  a  life  free  from 
anxiety  and  excitement.  The  patient  who  has 
habitually  been  addicted  to  the  over-ingestion 
of  food  must  be  restricted  as  to  his  diet.  The 
patient  with  damaged  kidneys  must  be  sub- 
jected to  a  regimen  which  will  enable  these 
organs  to  do  their  work  properly. 

A  mistake  that  is  often  made  is  in  treating 
these  cases  all  alike  and  regarding  them  as 
primarily  disease  of  the  kidney.  For  instance, 
a  patient  with  kidneys  damaged  by  disease  may 
often  use  alcohol  in  moderation  with  thera- 
peutic benefit;  the  patient  whose  condition  is 
secondary  to  mental  strain  may  often  be  bene- 


44  BLOOD-PRESSURE 

fited  by  the  ingestion  of  food,  and  by  a  lux- 
urious mode  of  life  which  is  entirely  contra- 
indicated  in  the  patient  whose  condition  is 
that  of  the  so-called  gouty  diathesis,  or,  as  we 
have  expressed  it,  secondary  to  the  breaking 
down  of  the  chemical  functions  of  the  body. 
So  no  hard-and-fast  rules  can  be  laid  down  for 
the  management  of  high-pressUre  without  re- 
gard to  its  origin.  The  influence  of  drugs  is 
also  a  matter  depending  upon  the  nature  of 
each  case. 

The  distinction  which  we  have  drawn  be- 
tween high-pressure  i:ases  and  low-pressure 
cases  presents  an  immense  advantage  in  the 
power  of  discrimination  between  therapeutic 
measures.  Particularly  is  this  true  in  regard 
to  hydrotherapy. 

The  general  s-tatement  may  be  made  that 
warm  bathing  is  indicated  in  high-pressure 
cases,  and  cold  bathing  only  in  primary  low- 
pressure  cases — with  this  distinction,  however, 
that  cold  bathing  is  contraindicated  in  high- 
pressure  cases,  while  warm  bathing,  and  even 
hot  baths,  may  be  beneficial,  and  often  are  in 
low-pressure  cases. 


MANAGEMENT  OF  HIGH-PRESSUJ^E  CASES     45 

These  facts  are  nowhere  better  illustrated 
than  in  the  two  great  modern  applications  of 
hydrotherapy— the  Nauheim  and  Brandt  sys- 
tems. In  the  former  we  are  dealing  with  high- 
pressure  Tases,  though  frequently,  indeed,  in 
the  stage  of  secondary  low  arterial  tension. 
In  the  latter  we  are  dealing  with  the  primary 
low  arterial  tension  of  acute  disease. 

The  beneficial  effect  of  systematic  warm 
bathing,  preferably  with  the  addition  of  sa- 
lines, whether  combined  or  not  with  resistance 
exercises,  in  high-pressure  cases  with  a  tend- 
ency to  cardiac  dilatation,  is  very  striking. 
Equally  striking  is  the  injury  observed  from  a 
persistence  in  taking  cold  baths  by  elderly  peo- 
ple at  the  present  time  who  fell  under  the  in- 
fluence of  certain  popular  doctrines  years  ago, 
which  entailed  a  Spartan  regimen  including 
cold  baths  and  coarse  food. 

The  Nauheim  treatment  is  particularly  ap- 
plicable to  this  form  of  disease,  no  matter  what 
its  origin,  and  its  great  success,  though  sup- 
posed to  be  due  to  a  direct  action  upon  the 
heart,  is  really  due  to  the  correction  of  dis- 
order of  the  arterial  system,  particularly  in 


46  BLOOD-PKESSURE 

cases  in  which  there  is  a  commencing  second- 
ary low  arterial  tension. 

The  baths  are  essentially  tepid  baths  with  the 
addition  of  saline  ing-redieiits  which  have  an 
action  upon  the  peripheral  circulation. 

The  growth  of  this  treatment,  met  as 
it  has  been  at  first  with  surprised  incredulity, 
and  later  with  blind  faith,  is  now  being  ana- 
lytically studied  and  is  found  to  be  applicable  to 
many  patients  in  many  places  without  much 
complication  of  detail. 

The  characteristic  Nauheim  treatment  as 
recommended  by  Schott  is  not  really  a  very 
warm  bath.  It  is  never  given  above  95°,  and 
even  as  low  as  88°  F.  The  presence  of  car- 
bonic acid  and  the  salines  causes  a  distinct  im- 
pression upon  the  skin. 

The  Schott  treatment,  therefore,  must  not 
be  confounded  with  the  valuable  procedure  of 
ordinary  hot  bathing  in  persons  who  have 
feeble  circulation.  The  former  procedure 
might  be  accompanied  by  certain  dangers  in 
persons  with  defective  kidneys,  while  ordi- 
nary hot  bathing  with  perhaps  the  addition  of 
bicarbonate  of  soda  has  no  such  danger.    Then 


MANAGEMENT  OF  HIGH-PRESSURE  CASES     47 

again,  the  characteristic  exercises  are  an  im- 
portant part  of  the  Schott  method. 

Concerning  foreign  health  resorts  Sansom 
makes  the  following  wise  remarks : 

"  The*  patient  is  apt  to  misunderstand  the 
word  '  cure '  as  applied  to  the  treatment  of 
the  foreign  health  resorts,  and  invests  proc- 
esses there  with  a  certain  glamour.  He  pre- 
fers, it  may  be,  the  counsel  of  a  prophet  who 
bids  him  do  some  great  thing,  to  the  advice  of 
a  friendly  doctor  who  has  carefully  watched 
the  signs  of  his  disease." 

High-pressure  cases  are  often  met  with  in 
men  who  literally  lead  a  life  of  high-pressure. 
The  successful  business  man  who  overworks 
and  worries,  and  who  uses  alcohol,  is  very  apt 
to  develop  arterial  changes  and  a  tendency  to- 
wards pathologic  high-tension.  To  such  per- 
sons, and  indeed  to  many  others,  the  neces- 
sity of  periods  of  relaxation  as  a  requisite  to 
the  maintenance  of  health  is  very  great.  The 
most  foolish  thing  that  any  successful  man  can 
do  is  to  work  throughout  the  year  without  an 
adequate  vacation,  and  it  is  a  rather  curious 
practical  observation,  even  among  professional 


48  BLOOD-PRESSURE 

men,  that,  in  the  long  run,  the  actual  income  of 
the  year  is  not  diminished  by  taking  several 
months  of  travel  and  recreation.  The  im- 
proved morale,  the  wider  view  of  the  world, 
and  the  coming  in  contact  with  new  people, 
more  than  compensates  for  the  actual  loss  of 
income  during  the  period  of  cessation  of  work. 
Any  man  whose  work  is  not  purely  routine  is 
the  gainer  by  a  sufficient  vacation,  and  by  de- 
voting some  attention  to  the  cjuestion  of  pleas- 
ure and  rest. 

When  health  is  considered,  in  view  of  our 
present  knowledge  of  the  progress  of  the  cir- 
culatory degeneration  which  goes  hand  in  hand 
with  the  advance  of  years,  and  which,  as  pre- 
viously stated,  is  particularly  liable  to  attack 
those  whose  lives  are  most  successful,  the  mat- 
ter of  rest  and  recreation  becomes  one  of  evi- 
dent importance. 

Unfortunately,  if  the  pursuit  of  pleasure  be 
put  off  too  long,  the  faculty  of  the  enjoyment 
of  a  quiet  life  is  lost.  It  is  extremely  impor- 
tant that  each  individual  should  develop  inter- 
ests during  early  life  that  may  occupy  him 
during  periods  of  cessation  of  work,  so  that 


MANAGEMENT  OP  HIGH-PRESSURE  CASES     49 

if  the  time  comes  when  he  suffers  from  high 
arterial  tension,  and  is  ordered  by  his  physician 
to  travel  and  rest,  he  may  be  able  to  take  an  in- 
terest in  the  things  of  the  pleasure-seeking 
world  afid  not  fret  and  worry  through  a  period 
of  so-called  relaxation,  only  to  return  to 
business  to  find  even  that  distasteful  be- 
cause of  ill-health.  Instances  of  this  kind  have 
been  observed  in  which  it  seemed  the  part  of 
humanity  to  allow  such  a  man  to  "  die  in  the 
harness,"  as  it  has  been  expressed,  that  is,  there 
are  certain  cases  of  the  high-tension  type  that 
have  gone  beyond  the  point  where  much  is 
gained  by  a  change  of  occupation.  It  is  im- 
portant, therefore,  that  high-tension  cases  be 
early  recognized,  so  that  proper  attention  may 
be  given  to  the  conduct  of  their  lives,  and  the 
care  of  their  circulation. 

The  effect  of  temperament  upon  the  progress 
of  high-tension  cases  is  marked.  A  man  with 
a  naturally  cheerful  disposition  who  is  active 
in  the  pursuit  of  pleasure,  even  though  this  be 
accompanied  by  the  abuse  of  stimulants,  suf- 
fers less  from  the  condition  of  high  arterial 
tension  than  does  the  individual  with  the  same 


50  BLOOD-PRESSURE 

physical  ailments  who  is  prone  to  mental  anx- 
iety and  depression.  The  reason  for  this  is 
probably  a  complicated  matter  of  the  reaction 
of  the  brain  upon  the  vasomotor  system. 

It  is  certainly  a  fact  that  many  men  prone  to 
conviviality  go  on  living  with  this  high  ar- 
terial tension  in  the  circulation,  while  others 
of  a  different  temperament  sink  rapidly 
through  the  grades  of  cardiac  hypertrophy, 
broken  compensation,  renal  insufficiency,  and 
circulatory  failure,  to  death. 

Hence,  the  one  most  important  condition  in 
the  management  of  high-tension  cases  is  the 
removal,  if  possible,  of  overwork,  particularly 
mental  work,  of  worry,  and  indeed,  all  de- 
mands that  may  put  the  nervous  system  under 
a  strain. 

The  truth  of  this  is  remarkably  shown  by  the 
occasional  observation  of  a  man  who,  having 
developed  high  arterial  tension,  cardiac  hyper- 
^trophy  and  albuminuria  during  the  course  of  an 
exciting  and  successful  business  career,  has 
finally  put  his  affairs  in  the  form  of  an  estate, 
and  settled  down  to  a  life  of  ease  and  enjoy- 
ment of  quiet  pleasures.     In  such  a  man  I 


MAKAGEMENT  OF  HIGH-PRESSUKE  CASES    51 

found  the  heart  large,  but  not  overactive,  an 
entire  absence  of  arterial  high-tension,  the  kid- 
neys doing  their  work  reasonably  well,  and 
indeed,  the  whole  condition  showing  a  state 
not  characterized  by  advancement.  This  is  no 
fancy  picture,  but  a  matter  of  actual  observa- 
tion. 

There  are  a  considerable  number  of  men  in 
the  position  where  they  must  choose  between 
a  few  years  under  the  conditions  in  which  they 
are  at  present,  and  a  good  many  more  years 
under  circumstances  of  less  strain. 

No  condition  is  so  easy  to  remove  tempo- 
rarily by  treatment  as  high  arterial  tension. 
The  administration  of  an  efficient  dose  of  one 
of  the  nitrites  is  as  striking  in  its  effect  as  any 
therapeutic  measure  in  all  medicine.  The 
trouble  is  that  the  effect  is  but  transitory,  and 
that  there  are  certain  disagreeable  by-effects, 
such  as  irritation  of  the  heart,  if  the  doses  are 
too  often  repeated.  For  this  reason,  much 
judgment  is  necessary  for  the  proper  adminis- 
tration of  the  vaso-dilators  in  high-tension 
cases. 

Some  physicians  give  these  drugs  three  or 


62  BLOOD-PRESSURE 

four  times  a  day,  and  flatter  themselves  that 
they  are  keeping-  down  arterial  tension. 
Others,  who  know  better,  give  the  drug  every 
hour,  and  really  succeed  in  relieving  arterial 
pressure. 

The  prolonged  treatment  of  high-tension 
must  be  principally  hygienic,  but  while  we  have 
not  any  belief  that  a  few  doses  of  nitroglycerine 
during  the  day  w^ill  permanently  effect  a  lower- 
ing of  tension^  still,  while  other  methods  are 
being  employed  it  is  a  useful  procedure,  as  it 
relieves  blood-pressure  at  intervals,  and  gives 
the  circulation  an  opportunity  to  take  ad- 
vantage of  anything  that  is  gained  by  other 
measures.  As  a  matter  of  fact,  in  the  earliest 
stages  of  this  condition,  a  few^  doses  may  for  a 
considerable  time  counteract  a  decided  tend- 
ency to  arterial  tension. 

In  the  treatment  of  high-pressure  cases  we 
are  confronted  with  the  fact  that  while  we  are 
treating  high  arterial  tension,  the  greatest 
danger  to  be  feared  is  secondary  low  arterial 
tension.  The  problem  is  to  remove  from  the 
heart  the  demand  for  the  maintenance  of  high- 
tension    in    order    to    avert    the    time    when, 


Management  of  high-jpressure  cases   53 

through  exhaustion,  it  cannot  maintain  even  a 
normal  pressure.  The  mere  reduction  of  high- 
pressure  by  the  dilatation  of  the  peripheral  ar- 
teries, when  the  demand  on  the  part  of  the 
system  tor  a  high  arterial  pressure  has  not 
been  removed,  often  results  merely  in  an  irri- 
tation of  the  heart. 

This  is  often  observed  clinically  when  nitro- 
glycerine is  used  indiscriminately  and  per- 
sistently in  high-tension  cases,  particularly  of 
the  nephritic  type.  Quite  frequently  where  a 
condition  of  irritation  has  come  about,  the  sub- 
stitution of  digitalis  will  result  in  a  calming  of 
the  circulation,  and  an  apparent  disappearance 
of  tension  that  is  surprising  to  those  who  have 
not  tried  this  experiment. 

The  drug  treatment  of  high-pressure  cases 
must  be  managed  by  an  intelligent  observer 
who  subordinates  theoretic  considerations  to 
practical  results. 

The  iodid  of  soda  used  persistently  has  a 
beneficial  effect  upon  patients  in  whom  there 
has  been  established  a  tendency  to  high-tension 
and  progressive  deterioration  of  the  heart- 
muscle. 


54  BLOOD-PRESSURE 

It  has  seemed  to  me,  and  my  observations 
have  been  confirmed  by  others,  that  even  in 
very  bad  cases  of  this  kind,  much  advantage 
results  from  the  use  of  this  drug  in  this  way. 

Ordinarily  it  is  presented  in  a  solution  of 
equal  parts  of  iodid  of  soda  and  water,  and 
given  in  doses  of  two  to  fifteen  drops  in  half 
a  glass  of  water  after  meals.  It  is  a  matter  of 
experiment  to  determine  how  much  each  pa- 
tient can  tolerate.  Ordinarily  five  drops  can  be 
taken  over  a  long  period  of  time,  although  a 
considerable  number  of  patients  can  only  take 
two  or  three. 


CHAPTER  VI 

* 

SOME     OBSCURE     SYMPTOMS     OF     CIRCULATORY 

DISORDER^    WITH    A    CONSIDERATION    OF 

THEIR  SIGNIFICANCE 

Not  all  symptoms  of  circulatory  failure  are 
comprised  in  dyspnea,  edema,  and  visible  con- 
gestion or  anemia,  though  these  are  the  car- 
dinal indications.  There  are  certain  symptoms 
of  obscure  origin  that  are  traceable  to  circula- 
tory disease,  and  are  only  overcome  when  that 
is  given  proper  attention. 

In  elderly  people  one  of  the  most  frequent 
and  troublesome  of  symptoms  is  that  of  head 
noises.  I  have  under  observation  at  the  present 
time  no  less  than  four  patients  who  have  suf- 
fered over  long  periods  of  time  from  noises 
referred  to  the  ear,  which  they  described  as 
puffing  or  blowing  sounds,  and  which  have 
been  extremely  annoying.  These  patients  had 
all  been  systematically  and  heroically  treated 
for  ear  disease  without  benefit,  but  when  the 

55 


56  BLOOD-PRESSURE 

circulation  was  properly  controlled  the  noises 
became  so  slight  as  not  to  be  complained  of, 
and  a  good  deal  of  the  time  not  to  be  noticed. 

These  patients  are  usually  found  in  the  group 
of  commencing  secondary  low  arteri-al  tension. 
The  explanation  of  these  sounds  would  seem  to 
be  the  circulation  of  blood  through  badly  filled 
blood-vessels  in  the  neighborhood  of  the  organ 
of  auditory  sensation. 

There  is  no  class  of  cases  that  has  given 
greater  satisfaction,  because  it  is  possible  to 
relieve  a  condition  that  has  caused  much  suf- 
fering, particularly  at  night. 

Another  obscure  manifestation  of  circulatory 
disorder  is  the  simulation  of  slight  attacks  of 
paralysis.  These  are  often  overlooked  unless 
they  are  watched  for.  They  consist  of  a  tem- 
porary slight  loss  of  power  of  a  transient  nature, 
on  the  right  or  left  side  of  the  body.  The  pa- 
tient usually  describes  the  attack  as  a  "  clumsi- 
ness "  of  a  leg  or  an  arm.  If  on  the  right  side 
of  the  body  there  is  sometimes  a  slight  loss  of 
power  of  speech,  in  that  certain  words  are  miss- 
ing. The  patient  usually  considers  this  a  tem- 
porary failure  of  memory.     These  manifesta- 


CIRCULATORY  DISORDER  57 

tions  are  the  same  as  often  indicate  more  se- 
rious disease  of  the  brain  with  impending 
thrombosis.  However,  in  many  cases,  atten- 
tion to  the  general  circulation  will  entirely  re- 
move the*symptoms,  so  that  it  is  hard  to  believe 
that  the  condition  was  purely  local  in  origin. 

There  is  a  class  of  obscure  symptoms  of  cir- 
culatory disorder  which  consists  of  pain  in 
various  parts  of  the  body.  How  much  of  this 
is  purely  circulatory,  and  how  much  of  it  be- 
longs to  the  gouty,  rheumatic,  and  nutritional 
disorders  that  are  common  in  the  same  class  of 
patients,  is  often  hard  to  determine.  It  is  sug- 
gestive that  these  painful  conditions  arise  at 
times  of  circulatory  debility  and  improve  when 
the  circulatory  disease  is  in  abeyance.  At- 
tacks of.  sciatica  of  a  persistent  and  trouble- 
some nature  are  particularly  apt  to  occur  in  pa- 
tients commencing  to  suffer  from  secondary 
low  arterial  tension. 

There  is  a  really  pitiable  set  of  patients  that 
might  be  mentioned  here,  though  perhaps  not 
quite  logically.  These  are  the  patients  who 
have  developed  a  very  painful  and  chronic  neu- 
ritis subsequent  to  attacks  of  extreme  circula- 


58  BLOOD-PRESSURE 

tory  edema  of  the  lower  extremities.  It  may 
be  only  a  coincidence,  but  these  have  been 
among  the  most  difficult  patients  to  relieve  that 
have  come  under  observation  in  connection 
with  the  treatment  of  circulatory  disease. 

The  obscure  symptoms  of  circulatory  disease 
would  not  be  complete  without  a  consideration 
of  the  things  that  may  happen  during  the  stage 
of  high  arterial  tension.  Nose-bleed  of  a  trou- 
blesome character  is  a  frequent  occurrence,  and 
in  cases  where  one  is  puzzled  to  decide  between 
primary  and  secondary  low  arterial  tension, 
the  history  of  a  period  during  which  nose-bleed 
was  very  troublesome  may  be  of  help.  It  is 
surprising  how  often  this  history  is  elicited 
from  patients  who  come  for  the  first  time  in 
the  stage  of  broken  compensation. 

The  number  of  conditions  due  to  congestion 
secondary  to  general  circulatory  disease  that 
are  mistaken  for  diseases  of  local  origin,  is 
very  great.  The  most  striking  of  these  is,  per- 
haps, congestion  of  the  liver. 

This  condition  develops  gradually,  so  that 
the  blood  becomes  congested  in  the  liver,  giv- 
ing rise  to   functional   derangements   of  this 


CIRCULATORY  DISORDER  59 

organ,  and  of  the  other  organs  of  digestion. 
The  Hver  is  enlarged  and  tender  on  pressure, 
and  the  condition  is  often  accompanied  by  very 
marked  disorder  of  the  stomach,  on  account  of 
which  it  is  frequently  mistaken  for  primary 
gastric  disease.  That  this  is  not  the  case  is- 
proven  by  the  fact  that  the  condition  is  relieved 
only  when  the  circulation  is  strengthened. 

There  is  a  class  of  cases  in  which  circulatory 
disorder  is  shown  in  its  pulmonary  effects. 
There  is  persistent  congestion  of  the  lungs, 
often  with  a  tendency  to  the  accumulation  of 
serum  in  one  or  both  pleural  cavities.  These 
patients  may  often  have  a  fairly  good  systemic 
circulation  and  very  obscure  indications  of  car- 
diac disease.  The  interference  is  apparently 
with  the  function  of  the  right  side  of  the  heart. 
Two  patients  of  this  character  were  watched 
over  a  long  period  of  time,  while  the  pul- 
monary congestion,  involving  repeated  at- 
tacks of  bronchitis  and  slight  edema,  ren^ 
dered  them  incapable  of  work.  The  symptoms 
of  circulatory  disorder  are  obscure  because  so 
much  more  accentuated  in  the  thoracic  organs 
than  elsewhere. 


60  BLOOD-PKESSURE 

Circulatory  disorder  may  also  show  itself  in 
its  effect  upon  the  function  of  the  brain  by  at- 
tacks of  acute  mania,  or  more  often  by  the  de- 
velopment of  a  chronic  mania. 

Changes  in  the  arteries  in  elderly  people  are 
apt  to  be  characterized  by  changes  in  disposi- 
tion, by  affections  of  the  memory,  and  by  im- 
pairment of  judgment.  That  these  symptoms 
are  traceable  to  circulatory  derangement  is 
shown  by  the  fact  that  their  course  is  markedly 
affected  by  the  treatment  of  the  circulation. 

Disorder  of  the  circulation  in  persons  past 
maturity  is  sometimes  shown  by  so  striking  a 
manifestation  as  general  convulsions.  These 
patients  are  often  supposed  to  be  suffering  from 
idiopathic  epilepsy.  However,  the  attacks  are 
so  promptly  relieved  by  appropriate  treatment 
directed  to  the  circulation,  which  would  have 
no  effect  whatever  in  epilepsy,  that  this  may  be 
eliminated  from  the  diagnosis.  Of  course, 
there  are  relatively  rare  cases  in  which  real 
epilepsy  begins  late  in  life. 

A  group  of  symptoms  on  the  border  line  be- 
tween neurotic  and  circulatory  disturbances 
forms  in  its  sum-total  a  large  proportion  of  the 


CIKCULATORY  DISORDER  61 

sufferings  of  humanity.  Abnormal  sensations 
in  the  extremities,  numbness  and  tingHng  of 
the  hands  and  feet,  a  feehng  of  formication  ex- 
tending up  the  legs  and  thighs,  abnormal  cold- 
ness of  the  hands  and  feet,  cramps  in  the  mus- 
cles of  the  legs  occurring  at  night,  and  the  tend- 
ency of  the  extremities  to  "  go  to  sleep,"  as  it 
is  called — all  these  things  may  be  pure  neu- 
roses, but  often  enough  there  is  a  circulatory 
element  in  their  causation. 

As  in  a  preceding  paragraph  in  this  chapter, 
we  may  again  suggest  that  the  therapeutic  test 
will  decide  how  much  of  this  is  due  to  disorder 
of  the  circulation.  Many  times  the  symptoms 
disappear  when  the  circulation  is  properly  reg- 
ulated. A  few  doses  of  nitroglycerine  have 
stopped  all  complaint  of  cold  extremities  in 
many  patients  of  this  type.  The  possible  se- 
verity of  pain  due  to  interference  with  the  cir- 
culation is  well  shown  in  cases  of  embolism  of 
the  extremities  in  the  course  of  circulatory 
disease.  No  one  who  has  observed  this  acci- 
dent will  doubt  that  pain  of  the  severest  type 
may  be  due  to  interference  with  the  circulation. 


CHAPTER  VII 

'THE   MANAGEMENT   OF   SECONDARY   LOW- 
PRESSURE    CASES 

The  treatment  of  low  arterial  tension  which 
is  secondary  to  long-existing  high-tension  con- 
ditions has  two  elements — first,  the  correction 
of  circulatory  errors  by  the  action  of  drugs 
which  have  the  power  to  modify  physiologic 
forces  in  various  parts  of  the  circulatory  cir- 
cuit, and,  second,  the  restoration,  as  far  as  pos- 
sible, of  the  health  of  the  tissues  upon  which 
denangements  of  function  are  often  founded. 

The  attention  in  diseases  of  the  circulatory 
apparatus  is  too  often  concentrated  upon  the 
first.  In  instances  of  temporary  embarrass- 
ment, or  of  extra  demands  on  account  of  com- 
plicating diseases,  this  first  element  becomes  of 
supreme  importance,  but  in  the  long-run  it  is 
the  second  element  upon  which  success  in  the 
care  of  circulatory  disorders  is  dependent. 

62 


SECONDARY  LOW-PRESSURE  CASES         63 

In  this  connection  it  is  important  to  differ- 
entiate between  the  symptoms  and  the  disease. 
Dropsy  of  the  dependent  portions  of  the  body 
is  a  symptom  which  does  not  always  demand 
treatmeat.  If  of  moderate  degree,  and  depend- 
ent upon  well-understood  causes,  it  is  often  the 
part  of  good  judgment  to  undertake  the  second 
element  of  treatment,  neglecting  for  the  time 
being  the  symptom,  the  removal  of  which 
would  require  intervention  in  the  physiologic 
activity  of  the  heart,  such  as  might  neutralize 
treatment  directed  to  the  circulation  as  a 
whole ;  indeed,  there  is  often  much  harm  done 
in  such  cases  by  violent  attacks  upon  symptoms. 

Most  writers  on  circulatory  disease  have 
passed  over  with  scant  consideration  the  man- 
agement of  cases  with  general  edema  and  stead- 
ily progressive  symptoms,  which,  if  not 
checked,  uniformly  lead  to  a  fatal  termination. 
It  is  unscientific  to  disregard  these  cases  in 
considering  various  forms  of  treatment  at 
length,  dismissing  them  with  a  single  clause. 
This  is  frequently  done  in  speaking  of  the 
Nauhelm  treatment,  progressive  cases  being 
usually  spoken  of  as  unsuitable.     There  is  al- 


64  BLOOD-PRESSURE 

ways  the  possibility  in  any  particular  case  that 
we  may  be  mistaken  in  our  estimate  of  it,  and 
the  patient  is  entitled  to  the  treatment  even  at 
the  risk  of  discrediting  the  system  by  the  limi- 
tation of  results  because  of  the  severity  of  the 
case. 

As  physicians  engaged  in  the  general  prac- 
tice of  medicine,  who  must  do  our  best  for 
those  who  place  themselves  under  our  care,  it 
is  our  duty  to  study  the  best  plan  for  every 
stage  of  a  case,  and  to  contest  skilfully  and 
hopefully  every  sign  of  the  progress  of  disease. 
In  the  whole  range  of  circulatory  disease  there 
is  no  condition  which  will  so  tax  the  knowl- 
edge and  patience  of  the  physician  as  the  man- 
agement of  this  low  arterial  tension  which  is 
secondary  to  high  arterial  tension. 

The  importance  of  recognizing  this  class  of 
cases  is  very  great,  because  the  methods  of 
treatment  which  tend  to  the  relief  of  the  condi- 
tion are  not  those  which  give  the  most  satisfac- 
tory immediate  symptomatic  results,  or  those 
which  are  applicable  to  low  arterial  tension 
which  has  not  been  preceded  by  high  arterial 
tension. 


SECONDARY  LOW-PRESSURE  CASES        65 

.  It  is  true  that  with  many  of  these  patients 
we  are  justified  in  the  use  of  means  which 
temporarily  give  relief  and  symptomatic  re- 
sults. 

In  primary  low  arterial  tension  the  heart- 
muscle  is  in  a  position  to  recover  its  tone  if 
depleted  by  acute  disease,  or  to  develop  a  com- 
pensatory hypertrophy  if  overtaxed  by  defect- 
ive valves. 

In  secondary  low  arterial  tension  the  heart 
has  already  for  the  time  being  exhausted  its 
power  of  compensatory  hypertrophy,  and, 
while  the  tendency  to  resistance  in  the  arteries 
persists,  there  is  no  adequate  response  on  the 
part  of  the  heart. 

Little  is  gained  symptomatically  in  extreme 
cases  by  the  use  of  vaso-dilators,  because  the 
blood-pressure  is  already  low.  Little  is  gained 
by  digitalis,  because  the  heart-muscle  is  not  in 
a  position  to  respond.  The  combination  of 
drugs  of  the  digitalis  group  with  drugs  of  the 
nitrite  group  produces  a  certain  amount  of 
symptomatic  response,  but  in  the  end  does  not 
produce  permanent  results  unless  combined 
with  measures  that  will  hold  the  advantage 


66  BLOOD-PRESSURE 

gained.  Excessive  drugging  is  a  mistake.  A 
single  large  dose  of  digitalis  at  night  is  often 
better  than  divided  doses.  A  good  fluid  extract 
put  into  a  capsule  and  swallowed  at  bedtime,  the 
dose  being  determined  by  experiment,  has  often 
proved  very  satisfactory.  Attention  to  the  di- 
gestive organs  is  often  of  the  utmost  impor- 
tance. Milk  is  often  badly  borne  and  should 
be  replaced  with  the  most  nutritious  food  that 
will  agree  with  the  patient. 

As  often  as  possible  these  patients  should  be 
put  upon  a  regimen  directed  to  the  improvement 
of  nutrition  and  to  the  healthfulness  of  the 
body  in  general,  hydrotherapy  in  the  form  of 
warm  saline  baths,  a  nutritious  diet  without  too 
much  regard  to  theories  as  to  gout  or  disease 
of  the  kidneys,  and  exercise  in  the  open  air  up 
to  the  point  where  dyspnea  interferes. 

We  are  dealing  often  enough  with  danger- 
ous conditions,  and  it  is  not  possible  to  compare 
the  result  in  a  particular  case  with  what  it 
would  have  been  under  other  circumstances. 
A  man  must  be  of  limited  experience  indeed 
who  has  not  seen  such  a  patient  do  better  when 
disregarding  advice  that  planned  treatment  of 


SECONDARY  LOW-PRESSURE  CASES        Ql 

such  a  condition  by  too  long  rest  in  bed  and  a 
diet  too  restricted.  In  cases  of  threatened 
circulatory  failure  those  remedies  that  have  a 
demonstrated  physiological  action  on  the  circu- 
,  lation  are  tools  to  be  used  for  the  correction  of 
defects  of  action  while  the  hygienic  measures 
mentioned  above  are  repairing  any  shortage  in 
vitality.  Each  drug  should  be  exhibited  by 
itself  and  ready  mixed  tablets  or  combinations 
reserved  for  less  serious  cases.  A  good  plan 
is  to  divide  the  day  into  periods  of  one  or  more 
hours  and  state  definitely  when  each  dose  is  to 
be  taken.  Thus  the  circulation  is  regulated  by 
various  adjustments  much  like  a  machine. 
Vaso-dilators  in  the  evening  are  often  well 
borne  and  useful  in  the  same  case  in  which  they 
are  harmful  in  the  morning. 

The  vitalizing  effect  of  a  change  of  climate, 
a  change  of  food,  and  of  massage  and  exercise 
should  always  be  remembered.  Under  wise 
management  a  patient,  the  subject  of  progress- 
ing circulatory  failure,  can  many  times  be 
rescued  from  a  situation  which  seemed  at  first 
most  discouraging. 


CHAPTER  Vin 

GENERAL    CONSIDERATIONS 

In  the  previous  chapters  the  author  has  sys- 
tematized his  conclusions  in  the  interpretation 
of  blood-pressure  as  affecting  the  heart,  brain, 
kidneys,  and  general  circulation. 

In  order  to  obtain  an  expression  of  opinion, 
there  was  published,  just  previous  to  the  writing 
of  this  little  book,  a  series  of  short  articles  in 
various  medical  journals.  These  elicited 
enough  discussion  to  show  that  the  subject  is 
one  in  the  mind  of  many  general  practitioners. 
Among  the  articles,  one  entitled  "  The  Im- 
portance of  Treatment  in  the  Early  Stages  of 
Arterial  Degeneration  "*  was  commented  upon 
by  Dr.  Beverley  Robinson,  of  New  York,  and  ,> 
others,  as  being  a  true  picture  of  the  condition 
described.  The  points  brought  out  were  that 
the  term  degeneration  of  the  arteries  is  a  better 
*  Medical  Record,  April  2,  1904. 
68 


GENERAL  CONSIDERATIONS  6§ 

term  than  arteritis,  arteriosclerosis  or  endar- 
teritis, because  it  is  less  definite  and  can  be  made 
to  include  functional  as  well  as  material  vices. 
This  condition  is  the  result  of  the  many  causes 
which  act  in  opposition  to  the  tendency  of  life 
to  go  on  without  loss  of  quality  or  impairment 
of  power — in  other  words,  it  is  the  failure  of 
repair,  and  the  failure  in  the  action  of  the 
mechanism  for  the  automatic  correction  of  ir- 
regularities in  the  circulation. 

The  light  thrown  upon  this  condition  by 
pathology  is  extremely  unsatisfactory  because 
•we  often  find  a  most  advanced  arterial  sclero- 
sis without  marked  symptoms,  and  we  find 
marked  symptoms  with  hardly  appreciable 
physical  changes.  The  degeneration  of  func- 
tion is  more  striking  during  life  than  degenera- 
tion of  tissue.  So  long  as  we  have  to  deal, 
then,  with  living  people,  the  perfection  or 
otherwise  of  the  processes  of  life  is  the  im- 
portant element.  This  element  is  entirely  be- 
yond the  view  of  the  microscopist. 

The  failure  of  circulation  may  be  due  to 
functional  causes  as  much  as  to  a  condition 
represented  by  appreciable  structural  change. 


iO  BLOOD-PRESSURE 

The  teaching  of  modern  science  has  been  too 
much  in  the  direction  that  phenomena  can  be 
wholly  explained  by  structure.  This  is  not 
true  of  the  working-  mechanism  of  the  human 
organism,  nor  indeed  is  it  true  even  of  me- 
chanical things.^ 

I  was  much  struck  recently  by  a  description 
of  his  own  case  as  given  by  a  gentleman  who 
has  achieved  success  in  life  through  the  able 
manner  in  which  he  has  managed  a  railroad. 
He  is  suffering  from  circulatory  failure,  and 
said :  ''  I  think  I  am  like  one  of  the  old 
engines  on  my  railroad — about  ready  for 
the  scrap-heap.  You  may  be  able  to  patch  me 
up  and  keep  me  going  for  a  little  while,  but 
you  cannot  make  me  new  again."  He  said  that 
when  an  engine  first  came  out  of  the  shop  it 
could  do  two  hundred  miles  a  day,  and  at  the 
end  be  just  as  good  as  at  the  start.  After  a 
while  there  would  be  a  little  leak  in  one  of  the 
valves  and  it  would  have  to  go  to  the  shop  to 
be  repaired.  Later  on  another  valve  would 
leak,  and  then  there  would  be  trouble  with  the 
fire-box.  When  this  once  began,  though  each 
time  the  engine  came  out  of  the  shop  it  would 


OENERAL  COKSIDERATIONS  71 

appear  to  be  all  right,  it  would  always  be  going 
back  again,  and  at  the  end  of  a  hundred  miles 
one  might  always  expect  something  to  be 
wrong.  He  said  further :  ''  I  employ  a  master 
mechanic  to  overhaul  the  engines  every  morn- 
ing, and  in  this  way  we  manage  to  keep  them 
going,  even  though  they  are  old;  but  there  al- 
ways comes  a  time  when  repairs  do  not  pay, 
and  then  they  are  sent  to  the  scrap-heap." 
This  was  a  simile  more  true  than  pleasant. 

There  is  something  about  a  piece  of  ma- 
chinery that  has  borne  the  stress  of  hard  usage 
that  is  very  like  the  behavior  of  the  human 
body  under  the  same  conditions.  It  pays  in  the 
long-run  to  buy  new  machinery,  and  it  would 
certainly  pay  to  get  a  new  body  if  that  were 
'possible.  A  new  automobile  can  be  managed 
and  kept  running  by  one  of  little  experience, 
but  to  keep  an  old  one  running  requires  the 
knowledge  of  an  expert. 

Machinery  can  be  replaced,  but  for  the 
human  being  there  is  only  one  body  as  far  as 
we  know,  so  we  must  make  the  best  of  it.  For 
this  reason  the  study  of  the  repair  of  the  failing 
human   organism    and    the    discovery   of   all 


^2  BLOOD-PRESSURE 

those  methods  by  which  it  may  be  kept 
smoothly  rumiing  are  well  worth  our  best  ef- 
forts. 

The  human  organism  is  a  much  better  ma- 
chine than  any  invented  by  man.  It  has  within 
itself  arrangements  for  the  repair  or  conceal- 
ment of  the  earlier  manifestations  of  many  se- 
rious affections.  In  a  way  this  is  a  disadvan- 
tage, because  the  earlier  signs  of  degeneration 
are  only  to  be  detected  by  the  trained  percep- 
tion of  a  skilful  observer.  This  is  particularly 
true  of  the  circulation.  The  earliest  sign  is  an 
irregularity  of  tension  in  the  arteries,  and  this 
goes  on  to  a  pretty  constant  high  arterial  ten- 
sion. The  inherent  forces  conceal  the  defect 
whenever  they  can  and  bring  about  a  compen- 
satory hypertrophy  of  the  heart. 

This  is  the  time  when  it  is  a  pleasure  and 
satisfaction  to  the  physician  to  step  in,  and  by 
proper  regime  and  treatment  regulate  the  ar- 
terial disorder,  and  the  causes  which  are  lead- 
ing to  it.  Once  in  a  while  there  is  a  patient 
who  will  submit  to  regulation  before  the  ap- 
pearance of  conscious  symptoms.  The  great 
majority  of  such  cases,  however,  have  come  un- 


GENERAL  CONSIDERATIONS  IS 

der  my  care  only  at  the  stage  when  the  hyper- 
trophied  heart,  having  wearied  of  the  burden  of 
maintaining  the  high  arterial  tension,  has  be- 
come feeble  and  probably  dilated.    Such  was  the 
case  of  the  patient  who  compared  his  state  with 
that  of  the  broken-down  motor.    He  presented 
the  picture  of  cardiac  failure — the  heart  dilated, 
with  blowing  murmurs,  a  feeble  and  irregu- 
lar pulse,  shortness  of  breath  on  the  slightest 
exertion,  albuminuria,  and  anemia.     It  was  a 
case  in  which  medical  aid  was   sought  only 
after  the  reparative  powers  of  the  body  had  ex- 
hausted themselves.     Two  years,  or  even  one 
year    earlier,    the    process    might    have    been 
checked,  so  that  the  scrap-heap's  day  would 
have  been  much  longer  postponed. 

To  make  an  estimate,  which  must  be  purely 
a  guess,  the  expectation  of  life  is  in  inverse 
proportion  to  the  postponement  of  treatment 
after  the  earliest  signs  of  irregularities  of  ar- 
terial tension  due  to  the  changes  of  degenera- 
tion. 

In  a  paper  read  before  the  New  York  County 
Medical  Association*  entitled  "  Ergot  in  Sur- 
*  Annual  Meeting,  April  i8,  1904. 


V4  BLOOD-PRESSURE 

gery,"  Dr.  Alfred  T.  Livingston,  of  New  York, 
said :  '*  In  this  connection  I  commend  to  your 
perusal  and  careful  consideration  a  brief  but 
most  valuable  and  pertinent  paper  by  Dr. 
Louis  F.  Bishop,  of  your  city  [see  current  vol- 
ume of  Journal  A.  M.  A.,  page  820].  The 
paper  in  question  reads  as  follows: 

"  The  Relation  of  Nature's  Provision  for 
Heart  Stimulation  and  Control  to  the  Use  of 
Cardiac  Drugs  in  Acute  Disease. 

*'  Before  plunging  into  the  indiscriminate 
use  of  drugs  which  have  the  property  of  causing 
the  heart  to  beat  more  strongly,  it  is  well  to 
consider  what  provision  has  already  been  made 
in  the  same  direction  by  the  body  itself,  and 
also  what  is  the  precise  object  of  such  inter- 
vention in  a  particular  case. 

"  The  heart  is  wonderfully  responsive  to  the 
demands  of  the  body  when  subject  to  exertion 
or  disease.  In  acute  conditions,  stimulation  in 
the  sense  of  urging  the  heart  to  expend  more 
energy,  is  seldom  demanded  except  in  sudden 
emergencies.  Fever  is  a  great  heart  stimu- 
lant, as  is  also  inflammation. 

"  The  use  of  the  term  *  heart  stimulants ' 


GENERAL  CONSIDERATIONS  >j5 

in  reference  to  drugs  that  are  used  in  the  course 
of  disease  with  the  idea  of  assisting  the  heart 
and  preventing  the  failure  of  its  powers  when 
they  are  most  needed,  is  a  crude  employment 
of  words,  and  has  led  to  much  misconception. 
Who  would  think  of  whipping  a  horse  that  was 
already  struggling  under  an  unusual  load,  or 
further  opening  the  throttle  of  an  engine  when 
it  was  going  too  fast? 

"  The  fact  is  that  we  have  but  few  heart 
stimulants  in  the  true  sense  of  the  word,  and 
we  hardly  ever  use  these.  The  only  time  when 
drugs  are  used  with  the  direct  purpose  of  stim- 
ulating the  heart  is  in  sudden  emergencies. 
Then  we  avail  ourselves  of  the  fact  that  many 
drugs  which  are  useful  as  heart  regulators  also 
possess  the  property  of  temporarily  stimulating 
the  heart.  The  best  heart  stimulants,  however, 
such  as  ammonia,  ether,  and  nitrite  of  amyl, 
are  poor  regulators,  and  the  best  regulators, 
such  as  digitalis,  strophanthus,  and  iodid  o£ 
soda,  are  poor  stimulants  when  quick  action  is 
^'     needed. 

"The  whole  question  of  heart  stimulation 
needs  revision  in  its  clinical  aspect.     A  good 


76  BLOOD-PRESSURE 

beginning  could  be  made  if  the  term  '  stimulant ' 
were  dropped  entirely  and  the  idea  of  regula- 
tion substituted.  A  hundred  lives  are  saved  by 
the  judicious  control  of  the  over-stimulation 
which  results  from  disease,  where  one  is  saved 
by  direct  stimulation  as  such.  The  only  excuse 
for  the  use  of  heart  stimulants  is  that  they  have 
been  misnamed,  and  are  useful  as  regulators. 

^'  The  misconception  of  the  importance  of 
stimulation  as  an  element  in  recovery  from  dis- 
ease has  unquestionably  led  to  much  harm. 
When  in  a  very  sick  person  it  is  found  that 
the  pulse  is  slow,  reflecting  only  the  weakness 
of  the  patient,  one  should  rather  rejoice  than 
otherwise.  Circulatory  failure  does  not,  as 
a  rule,  take  place  in  this  direction.  Primary 
low  arterial  tension  without  excessive  rapidity 
is  not  ordinarily  dangerous  if  let  alone.  Such 
a  heart  may  carry  on  its  work  successfully, 
while  if  injudiciously  drugged,  it  may  be  so 
exhausted  that  if  the  stage  of  the  rapid  and 
feeble  heart  be  reached,  there  may  not  be  re- 
serve force  enough  to  carry  the  patient  through 
the  disease.  I  have  repeatedly  seen  cases  in 
which,  on  account  of  simple  feebleness  of  the 


GENERAL  CONSIDERATIONS  77 

pulse  in  acute  disease,  the  patient  had  been 
drugged  beyond  measure,  with  the  result  that 
the  heart  and  pulse  were  showing  most  erratic 
action,  but  in  which,  the  occasion  for  the  origi- 
nal stimulation  having  passed,  the  withdrawal 
of  all  drugs  soon  restored  the  heart  action  and 
pulse  to  normal. 

"  Failure  of  the  heart  most  frequently  takes 
place  in  the  direction  of  increased  rapidity. 
This  is  probably  due  to  the  failure  of  a  very 
radical  element  in  the  living  organism  known 
as  inhibition.  In  connection  with  the  heart, 
the  nerves  which  conduct  this  impulse  from  the 
great  nerve  centers  which  seem  to  be  the  cen- 
ter of  life,  are  well  known.  The  same  influence 
in  one  form  or  another  affects  every  organ  and 
tissue  of  the  body.  On  it  depends  co-ordina- 
tion in  every  vital  process.  An  instance  of  its 
failure  to  act  is  seen  in  increased  patellar  re- 
flex, due  to  cutting  of  the  path  of  connection 
between  the  brain  and  the  muscles  of  the  thigh. 

"  So  increase  in  rapidity  of  the  heart  in  dis- 
ease tending  to  dissolution  is  a  very  radical 
thing,  and  is  only  successfully  combated  by 
measures  influencing  vitality  itself^  such  as  im- 


78  BLOOD-PRESSURE 

proved  nutrition  of  the  whole  body,  improve- 
ment of  the  nervous  system  at  large,  and  the 
removal  of  those  things  which  are  acting  con- 
trary to  the  interests  of  the  whole  physical 
economy.  I  can  remember  as  a  medical  stu- 
dent, bringing  to  bear,  when  opportunity  af- 
forded, every  known  heart  drug  in  the  attempt 
to  control  the  rapid  and  feeble  heart  action  of 
dying  patients,  and  I  could  not  understand  at 
that  time  why  so  little  was  accomplished. 

"  In  acute  disease,  while  there  is  life  there  is 
hope  of  the  restoration  of  the  patient  to  health, 
so  one  must  strongly  advocate  the  most  strenu- 
ous efforts  to  the  very  last  to  avert  the  tendency 
to  death;  but  there  are  certain  limits  beyond 
which  drugs  having  a  direct  influence  on  the 
heart  are  no  longer  useful.  If  the  patient  is 
to  be  saved  it  must  be  done  by  the  restoration  of 
the  inhibitory  force  by  measures  directed  to 
the  restoration  of  the  whole  bodily  economy. 
Hence  the  value  of  strychnin,  of  hydrother- 
apeutics,  of  nutrition,  and  above  all,  of  sleep, 
and  the  removal  of  exhausting  influences. 

*  "  Interesting  as  they  are,  and  important,  the 
consideration  of  the  mechanics  of  the  circula- 


GENERAL  CONSIDERATIONS  79 

tion  must  give  way  to  the  consideration  of  the 
patient  himself  as  an  individual.  There  is  a 
trite  saying  that  a  man  is  as  old  as  his  ar- 
teries, and  in  acute  disease  it  may  be  said,  as  a 
rule,  that* the  heart  is  as  good  as  the  man. 

"  The  moral  of  it  all  is  that  in  acute  disease 
the  question  of  cardiac  drugs  is  a  matter  that 
must  not  be  lightly  considered." 

In  American  Medicine,  April  2^,  1904,  was 
published  a  brief  note  entitled :  "  The  Im- 
portance of  Considering  the  Element  of  Vaso- 
motor Instability  in  Estimating  the  Signifi- 
cance of  Irregularity  of  Cardiac  Rhythm," 
which  read  as  follows : 

"  The  frequent  discrepancies  between  the 
heart-sounds  as  heard  by  the  stethoscope  and 
the  pulse  as  determined  by  palpation  must  have 
impressed  all  observers.  It  has  been  a  matter 
of  surprise  that  hearts,  which,  by  their  sounds, 
seemed  to  be  doing  good  work,  were  often  ac- 
companied by  a  pulse  giving  a  poor  impression, 
and,  on  the  other  hand,  cases  showing  irregu- 
larities of  the  heart-sounds  have  been  associ- 
ated with  a  pulse  showing  a  fair  degree  of 
regularity. 


80  BLOOD-PRESSURE 

"  When  it  is  remembered  that,  in  the  Hght  of 
evolution,  the  heart  is  constructed  of  the  same 
elements  as  the  blood-vessels,  and  is  only  a 
differentiation  of  the  circulatory  tube,  and 
v^^hen  it  is  appreciated  that  not  only  the  blood  of 
the  heart,  but  the  blood  of  the  whole  circula- 
tion, is  surrounded  by  a  muscular  envelope 
that  maintains  its  pressure,  it  can  easily  be 
seen  that  in  palpating  any  portion  of  this 
blood-containing  system,  the  variations  in 
pressure  will  be  a  complex  of  the  whole 
envelope,  and  not  merely  of  its  strongest 
portion. 

"  The  vasomotor  system  is  much  more  liable 
to  disorder  than  the  heart,  and  the  heart  is  able 
to  compensate  for  a  good  deal  of  misbehavior 
on  the  part  of  the  vessels,  but  in  compensating 
it  often  appears  to  be  misbehaving  itself. 
Thus,  one  may  fall  into  the  error  of  predicating 
disease  of  the  heart-muscle  when  the  trouble 
really  is  a  functional  derangement  of  the 
blood-vessels.  In  many  of  the  cases  that  are 
strikingly  benefited  by  the  Nauheim  treatment 
the  results  are  undoubtedly  obtained  by  a 
restoration  of  the  peripheral  circulation,  and 


GENERAL  CONSIDERATIONS  81 

the  relief  of  the  heart  from  a  struggle  to  com- 
pensate for  it. 

''  Not  only  clinical  but  pathologic  study  con- 
firms the  fact  that  diseases  of  this  class,  includ- 
ing myocarditis  and  nephritis,  have  their 
origin  most  often  in  degeneration  of  the  blood- 
vessels, at  first  functional,  and  then  organic. 
The  coronary  arteries  of  the  heart  become  in- 
volved and  then  the  heart-muscle  suffers.  The 
vaso-vasorum  of  the  blood-vessels  suffer,  and 
then  the  larger  vessels,  so  even  in  the  early 
stages  of  circulatory  symptoms,  the  relation- 
ships should  be  appreciated  and  the  hygiene  of 
the  peripheral  circulation  becomes  a  matter  of 
serious  supervision." 

This  elicited  the  following  reply  from  Dr. 
Albert  Abrams,  of  California  (author  -of 
"  Diseases  of  the  Heart ;  Their  Diagnosis  and 
Treatment"),  who,  under  the  title:  "A 
Clinical  Method  of  Determining  the  Vasomo- 
tor Factor    in  Blood-Pressure,"  *   said : — 

"  Dr.  L.  F.  Bishop,  in  a  contribution  on 
*  The  Importance  of  Considering  the  Element 
of  Vasomotor  Instability  in  Estimating  the  Sig- 
*  American  Medicine,  May  28,  1904. 


82  BLOOD-PRESSURE 

nificance  of  Irregularity  of  Cardiac  Rhythm/ 
pubhshed  in  American  Medicine,  April  23, 
1904,  directs  attention  to  a  significant  clinical 
paradox,  viz.,  the  discrepancy  often  existing 
between  the  heart-sounds  and  the  pulse — in 
other  words,  the  vigor  of  the  one  cannot  be 
gauged  by  the  strength  of  the  other.  My  own 
observations  tally  with  those  of  Bishop.  I  have 
frequently  noted  among  arteriosclerotics  and 
others,  that  a  high  blood-pressure  is  often 
coupled  with  the  local  evidence  ^f  cardiac  in- 
compensation.  When  the  heart-tones  are 
weak,  increased  blood-pressure  can  never  indi- 
cate a  vigorous  heart-action,  and  in  estimating 
the  vigor  of  the  latter,  blood-pressure  is  of  sub- 
sidiary value  only.  When  high  blood-pressure 
coexists  with  cardiac  enfeeblement,  a  vaso- 
motor factor  is  concerned  in  the  maintenance 
of  the  former,  this  increase  in  the  peripheral 
resistance  of  the  blood-vessels  acting  as  a  prop 
to  the  enfeebled  heart.  In  other  words,  the 
arterial  system  serving  the  objects  of  compen- 
sation acts  as  a  subsidiary  heart,  which  in  turn 
facilitates  the  circulation  of  blood.  In  this 
way,  as  I  view  it,  the  nervous  system,  through 


GE*[ERAL  CONSIDERATIOKS  83 

the  vasomotor  nerves,  may  compensate  an  im- 
paired myocardium. 

"I  have  accumulated  sufficient  data  to  war- 
rant recommending  the  following  method  for 
determining  the  vasomotor  factor  in  the  clin- 
ical measurement  of  blood-pressure.  In  my 
observations,  the  Riva-Rocci  instrument  was 
employed.  After  determining  blood-pressure, 
according  to  the  conventional  method,  the  pa- 
tient is  instructed  to  inhale  amyl  nitrite  from 
a  bottle,  after  which  procedure  the  blood-press- 
ure is  again  estimated,  and  the  difference 
noted.  The  arm-piece  of  the  instrument  need 
not  be  removed  until  the  investigations  are 
completed.  The  patient  must  be  instructed  not 
to  practice  forced  breathing  while  inhaling 
amyl  nitrite,  as  observation  has  taught  me 
that  tliis  physiologic  act  alone  will  reduce 
blood-pressure,  and  thus  negative  the  clinical 
findings.  Sufficient  amyl  nitrite  must  be  in- 
haled to  induce  its  physiologic  action,  viz., 
slight  duskiness  of  the  face,  fulness  in  the  head, 
and  relaxation  of  the  blood-vessels.  The  aver- 
age effect  of  inhalation  of  the  drug  in  the  nor- 
mal subject  is  to  cause  a  slight  increase  of 


U  BLOOD-Pl^ESSURfi 

blood-pressure,  varying  from  2  mm.  to  20  mm. 
The  primary  effect  is  to  depress  slightly  the 
blood-pressure,  but  it  rises  at  once.  1  am  in- 
clined to  conclude  that  in  the  average  healthy 
individual  inhalation  of  amyl  nitrite  relaxes  the 
arterial  walls  by  eliminating  the  vasomotor  in- 
fluence, thus  bringing  into  play  the  veritable 
cardiac  pressure.  My  observations,  extending 
over  a  period  of  one  year,  permit  me  to  formu- 
late the  follov^ing  conclusions: 

"  I.  Blood-pressure  is  an  expression  of  ac- 
tion of  two  chief  factors,  ventricular  force  and 
vasoconstriction. 

"  2.  Inhalation  of  amyl  nitrite  dissipates  the 
vasoconstrictor  factor,  and  brings  into  play  the 
ventricular  force  which  is  the  real  factor  to  be 
encouraged  in  a  failing  heart. 

"  3.  The  vasoconstrictor  factor  may  and 
does  compensate  myocardial  inadequacy,  for*it 
is  essential  in  most  cardio-arterial  diseases  for 
the  blood-pressure  to  be  maintained  to  afford 
better  nutrition  of  the  heart,  and  to  augment 
arterial  elasticity  as  a  means  of  establishing 
the  blood  circulation. 

"  4.  The  recognition  of  the  myocardial  and 


GENERAL  CONSIDERATIONS  8S 

vasomotor  factors  in  blood-pressure  guides  us 
correctly  in  the  administration  of  cardio-tonics. 

"  5.  In  the  individual  endowed  with  cardiac 
health,  the  removal  of  the  vasomotor  factor  by 
inhalation  of  amyl  nitrite  causes  an  increase  in 
blood-pressure,  whereas  the  converse  condition 
causes  the  latter  to  fall  and  the  degree  of  re- 
duction is  proportionate  to  the  degree  of  car- 
diac enfeeblement.  In  other  words,  the  high 
blood-pressure  in  myocardial  disease  is  main- 
tained by  an  augmented  tonus  of  the  vasomotor 
center.  Thus  the  blood-pressure  may  fall  from 
240  mm.  before,  to  180  mm.  after,  inhalation 
of  amyl  nitrite  in  arteriosclerotics  with  en- 
feebled hearts.  Even  this  reduction  in  blood- 
pressure  is  not  low  enough  to  correspond  with 
the  tones  of  the  feeble-acting  heart,  hence  one 
is  constrained  to  conclude  that  the  action  of 
the  amyl  nitrite  does  not  suffice  wholly  to 
eliminate  the  vasomotor  factor. 

"  6.  The  execution  of  the  foregoing  maneu- 
vers in  estimating  heart  vigor  is  by  no  means 
comparable  to  a  correct  method  of  cardiac  aus- 
cultation, although  the  latter  method  does  not 
indicate  how  much  of  the  cardiac  force  may  be 


S6  BLOOD-PRESSURE 

attributed  to  increased  peripheral  resistance; 
cardiac  auscultation,  in  conjunction  with  the 
sphygmomanometer  and  the  inhalation  of 
amyl  nitrite,  constitutes  the  ideal  method  for 
ehciting  the  real  condition  of  things. 

•"7.  In  estimating  blood-pressure  the  sphyg- 
momanometer only  gauges  the  force  of  the  left 
ventricle,  and  to  determine  the  sufficiency  of 
the  right  ventricle,  auscultation  of  the  pul- 
monic sounds  and  a  physical  examination  of 
the  lungs  are  alone  adequate. 

^'  I  have  encountered  a  number  of  individuals 
with  very  high  blood-pressure,  and  who  dem- 
onstrated no  cardiac  anomaly,  yet  the  blood- 
pressure  remained  the  same  after  as  before  the 
inhalation  of  amyl  nitrite.  In  about  half  of 
these  individuals  the  urine  was  light  in  color, 
of  low  specific  gravity,  contained  a  trace  of  al- 
bumin, and  was  excreted  in  increased  quanti- 
ties. Albumin  often  disappeared  when  the 
blood-pressure  was  spontaneously  lowered,  to 
reappear  when  the  pressure  rose,  hence  the  al- 
buminuria in  such  instances  could  be  correctly 
designated  as  the  albuminuria  of  high  blood- 
pressure." 


GENERAL  CONSIDERATIONS  87 

With  reference  to  "  Constitutional  Low  Ar- 
terial Tension,"*  the  following  was  published : 
"  It  will  be  found  that  there  are  many  patients 
who  give  evidence,  on  the  most  casual  examina- 
tion of*  the  circulation,  that  the  tension  in  the 
arteries  is  very  slight,  and  in  some  this  will  be 
found  a  constant  condition.  It  is  surprising 
how  little  tension  there  can  be  in  the  radial 
pulse  without  the  patient  suffering  from  any 
symptoms  of  circulatory  disease. 

''  This  low  arterial  tension  in  otherwise  ap- 
parently healthy  individuals,  is  undoubtedly  a 
departure  from  the  normal.  It  may  be  due  to 
an  unusual  relaxation  of  the  peripheral  circula- 
tion which  makes  it  possible  for  the  heart  to  do 
its  work  withjDut  little  effort.  Some  of  these 
patients  are  generally  feeble,  lacking  in  nerve 
force  and  unequal  to  strains.  Others,  how- 
ever, seem  to  respond  to  demands  for  physical 
or  nervous  effort,  and  when  so  responding 
there  is  an  improvement  in  the  tone  of  the  cir- 
culation. 

*'  When  seen  for  the  first  time  during  some 

*  New     York    Medical  Journal    and   Philadelphia 
Medical  Journal,  June  ii,  1904. 


88  fiLOOD-PRESSURE 

acute  affection  this  condition  may  give  rise  to 
apprehension  on  the  part  of  the  physician  as  to 
the  outcome  of  the  illness  for  which  he  has 
been  summoned.  When,  however,  the  patient 
can  be  watched  from  year  to  year  and  is  seen 
to  get  along  perfectly  well,  even  though  there  is 
this  lack  of  tone  in  the  circulation,  the  physi- 
cian comes  to  realize  that  with  that  individual 
it  is  a  physiologic  condition. 

"  There  is  another  form  of  low  arterial  ten- 
sion that  is  of  much  more  importance,  and  that 
is  the  low  arterial  tension  which  succeeds  the 
high  arterial  tension  of  chronic  Bright's  dis- 
ease. Here  we  have  to  deal  with  a  most 
serious  complication  of  the  disease.  It  means 
that  the  circulation  is  no  longer  maintained  by 
the  heart.  Thus,  it  may  be  stated  that  low 
arterial  tension  may  exist  in  certain  individuals 
without  great  significance,  but  that  if  it  has 
been  preceded  by  high  arterial  tension  it  is  a 
factor  of  grave  import.  With  this  condi- 
tion we  have  nothing  to  do  in  the  present 
discussion,  but  rather  with  low  arterial 
tension  that  is  a  reflex  of  a  constitutional 
condition. 


GENERAL  CONSIDERATIONS  89 

"  Experience  has  shown  that  nothing  is 
'  gained  with  these  individuals  by  the  use  of  drugs 
to  increase  arterial  tension.  It  is  quite  possible 
to  make  the  pulse  for  the  time  being  approxi- 
mate the  normal;  indeed,  this  often  happens 
spoiitaneously  when  the  heart  and  circulation 
are  physiologically  stimulated  by  exercise  or 
fever. 

^'  The  condition  is,  in  all  probability,  due  to 
an  inherent  defect  in  the  nervous  system, 
whereby  it  does  not  exercise  the  proper  control 
over  the  blood-vessels.  The  same  patients  who 
suffer  from  this  low  arterial  tension  are  very 
apt  to  manifest  other  symptoms  of  defective 
'  nervous  control,  and  the  removal  of  the  under- 
lying condition  will  bring  about  an  improve- 
ment in  the  circulation. 

"  The  most  important  element  of  treatment  is 
systematic  exercise.  These  patients  are  often 
dependent  for  their  well-being  upon  regular 
physical  exertion.  Often  they  feel  much  better 
if  they  can  take  a  brisk  horseback  ride  every 
day,  or  some  other  form  of  stirring  exercise. 
There  are  other  cases  in  which  it  is  found  that 
iron  and  arsenic  improve  the  condition  when  it 


90  BLOOD-PRESSURE 

becomes  very  marked.  In  still  other  cases  very 
hot  baths  take  the  place  of  vigorous  exercise 
and  improve  the  tone  of  the  circulation.  It 
should  be  remarked  that  this  is  a  secondary 
effect,  because,  if  the  circulation  be  examined 
immediately  after  the  bath,  it  will  be  found  to 
be  more  relaxed  than  usual. 

"  Although  one  would  expect  beneficial 
results  from  cold  bathing,  it  is  found  by 
experience  to  b^  unsatisfactory  in  cases  of 
constitutional  low  arterial  tension.  Such 
subjects  do  not  react,  and  the  effect  is  not 
satisfactory. 

^'  These  observations  refer  to  a  class  of  pa- 
tients who  are  not  suffering  from  any  definite 
disease,  but  who  realize  that  they  are  not  the 
same  as  other  people.  They  have  probably 
been  told  that  they  are  suffering  from  a  variety 
of  diseases,  according  as  the  phenomena  were 
supposedly  traced  to  one  or  the  other  organ. 
To  them  may  be  applied  the  rather  trite  remark 
that  they  are  suffering  from  a  condition  rather 
than  a  disease.  Such  patients  are  fortunate  if 
they  come  under  the  care  of  a  practitioner  who 
will  appreciate  the  condition  and  manage  it 


GENERAL  CONSIDERATIONS  91 

properly.  The  worst  thing  that  can  happen  is, 
that  there  should  be  repeated  efforts  to  cure 
supposed  disease  by  different  men  succeeding 
one  another." 

*'  Prostration  of  the  Circulation  "  *  was  the 
title  of  a  paper  which  read  as  follows :  ''  This 
term  is  used  in  reference  to  the  circulatory 
system  as  synonymous  with  neurasthenia  in 
relation  to  the  nervous  system.  Neurasthe- 
nia is  undoubtedly  founded  upon  a  malnu- 
trition or  an  exhausted  vitality  of  nervous 
tissue.  Prostration  of  the  circulation  is 
founded  upon  the  corresponding  elements,  but 
as  the  heart  and  blood-vessels  are  much  more 
open  to  direct  examination  than  the  nerves, 
there  are  signs  as  well  as  symptoms.  As  in 
neurasthenia  both  the  brain  and  the  peripheral 
nerves  participate  in  the  disease,  so  in  prostra- 
tion of  the  circulation  the  heart  and  blood- 
vessels are  involved.  Neurasthenia  and  pros- 
tration of  the  circulation  are  two  conditions 
that  have  many  correlations.  In  neurasthe- 
nia there  is  always  a  certain  amount  of  vaso- 
motor disturbance,  though  there  are  many 
*  Buffalo  Medical  Journal,  May,  1904. 


92  BLOOD-PRESSURE 

cases    in    which    the    circulation    is    entirely 
normal. 

"  In  prostration  of  the  circulation  there  is 
often  much  depression,  but  disturbances  of  sen- 
sation have  a  real  foundation  in  alterations  of 
the  blood  supply,  and  there  are  many  cases  in 
which  there  is  not  the  slightest  touch  of  neu- 
rasthenia. 

"  I  have  suggested  the  name,  prostration  of 
the  circulation,  to  cover  those  cases  in  which 
the  terms  myocarditis  and  arterial  degenera- 
tion are  too  harsh,  just  as  we  would  not  like 
to  speak  of  neurasthenia  as  insanity.  We  have 
for  a  long  time  needed  a  word  to  coveF 
those  cases  which  present  disturbance  of 
function,  and  which  are  perfectly  capable 
of  complete  recovery,  though  as  often  as  not 
they  go  on  to  the  manifestation  of  organic 
disease. 

"  The  following  case  which  I  saw  recently 
will  illustrate  the  point  I  wish  to  make.  The 
case  was  that  of  a  woman  who  had  worked  very 
hard  all  her  life,  had  become  run  down,  and 
began  to  find  that  it  was  difficult  for  her  to 
carry  on  her  occupation.     She  presented  the 


GENERAL  CONSIDERATIONS  93 

appearance  of  health ;  there  were  no  evidences 
of  kidney  disease,  and  no  history  of  dissipa- 
tion. She  complained  of  some  shortness  of 
breath  on  exertion,  particularly  when  there  was 
any  sudden  demand  upon  her  muscular  system. 
She  was  not  in  the  least  neurasthenic,  for  these 
conditions  were  perfectly  real  in  their  existence. 
The  arterial  pulse  was  soft  and  compressible; 
her  heart-sounds  were  feeble,  and  there  was  a 
soft  systolic  murmur  at  the  apex. 

"  It  seemed  to  me  a  simple  case  of  circulatory 
prostration,  and  one  that  was  capable  of  com- 
plete recovery  by  a  suitable  course  of  treat- 
ment. It  is  not  easy  to  describe  the  differen- 
tiation of  such  a  case  from  a  case  of  real  myo- 
cardial degeneration,  or  a  case  of  circulatory 
disease  in  which  the  kidneys  may  eventually  be 
the  principal  sufferers.  However,  there  is  this 
about  it — namely,  that  in  myocarditis,  irregu- 
larity of  force  and  rhythm  is  a  very  constant 
symptom,  and  in  commencing  arterial  degener- 
ation careful  search  should  be  made  to  discover 
some  signs  of  irregularity  of  cerebral  circula- 
tion. Cases  of  prostration  of  the  circulation 
show  marked  hepatic  symptoms,  principally  due 


94  BLOOD-PRESSURE 

to  the  staguation  of  the  circulation  in  the  liver. 
In  other  words,  in  simple  prostration  of  the 
circulation  the  blood  current  is  feeble,  but 
regular.  In  myocarditis  and  arterial  degener- 
ation it  is  irregular." 


CHAPTER  IX 

THE  ESTIMATION  OF  BLOOD-PRESSURE  AND  THE 

USE   OF   THE    NITRITES    FOR   ITS 

MODIFICATION 

The  estimation  of  the  condition  of  the  cir- 
culation usually  represented  by  "  feeling  the 
pulse"  stands  for  a  very  important  proce- 
dure in  the  routine  of  the  practice  of  medicine, 
and  is  the  one  element  of  a  physical  examina- 
tion that  is  probably  never  neglected  in  any 
case,  or  in  any  country.  For  this  reason  the 
estimation  of  the  pulse,  while  it  has  not  always 
lent  itself  to  the  most  scientific  classification, 
still  to  the  individual  physician  represents  a 
remarkable  amount  of  experience  and  observa- 
tion, checked  by  the  findings  of  subsequent 
events.  Now,  while  many  physicians  are  un- 
able to  express  in  words  what  they  feel  in  the 
pulse,  still,  very  often  indeed  their  conclusions 
are  correct. 

The  tactile  estimation  of  relative  blood- 
pressure   as    determined   by   the   experienced 

95 


96  BLOOD-PRESSURE 

touch,  and  checked  by  clinical  symptoms,  is 
usually  correct,  on  account  of  this  high  degree 
of  training.  There  is  a  possibility  that  some 
of  this  great  skill  of  the  profession  might  be 
lost  if  instrumental  observation  should  pos- 
sibly take  the  place  of  direct  examination,  just 
as  we  have  lost  skill  in  measuring  fever.  How- 
ever, the  introduction  of  instruments  of  pre- 
cision far  outbalances  the  benefits  of  the  skill 
created  by  their  absence. 

In  this  connection  the  question  is:  How 
may  technical  skill  in  clinical  pathology  be 
made  available  to  the  profession  at  large? 

It  will  be  noted  that  so  far  little  has  been 
said  as  to  the  actual  measurement  of  blood- 
pressure  in  the  vessels.  The  extensive  con- 
sideration of  this  is  left  to  works  devoted  to 
this  particular  branch  of  physical  exploration. 
It  is  undoubtedly  true  that  the  systematic  in- 
strumental measurement  of  blood-pressure  by 
various  instruments  will  eventually  lead  to 
important  clinical  results. 

As  remarked  in  the  first  chapter,  it  is  the 
difference  in  pressure  between  the  place  v/hcre 
the  blood  is  stored  and  the  place  where  it  is  re- 


THE  ESTIMATION  OF  BLOOD-PRESSURE     9  If 

quired,  together  with  the  element  of  resistance 
in  the  intervening  blood-vessels,  that  determines 
the  competency  of  the  circulation. 

The  instruments  and  skill  for  the  quantita- 
tive measurement  of  blood-pressure  are  still 
not  in  the  possession  of  the  majority  of  practi- 
tioners. It  is  enough  to  have  considered  at  the 
present  moment  the  philosophy  of  those  cases 
in  which  there  is  little  room  for  difference  of 
opinion  as  to  the  existence  of  high  or  low  press- 
ure. In  order  to  bring  this  branch  of  clinical 
observation,  as  well  as  others, within  easy  reach 
of  my  fellow  practitioners  engaged  in  the  gen- 
eral practice  of  medicine  as  distinguished  from 
those  engaged  in  teaching  and  pure  research 
work,  I  propose  in  the  near  future  to  establish 
in  a  physicians'  office  building  a  laboratory  of 
clinical  medicine  where  may  be  obtained  the 
use  of  instruments  and  the  services  of  those  re- 
cently trained  in  modern  methods  of  clinical 
pathology,  so  that  all  may  have  the  same  fa- 
cilities now  enjoyed  only  by  the  few  physicians 
whose  practice  justifies  the  maintenance  of  an 
independent  laboratory  and  staff  of  assistants. 

The  necessity   for  such   a   laboratory  will 


98  BLOOD-PRESSURfi 

always  be  felt  by  that  great  body  of  physi- 
cians who,  having  originally  been  fairly 
trained  in  the  clinical  methods  of  the  time  of 
their  tutelage,  have  become  preoccupied  by 
their  work,  and  do  not  feel  like  acquiring 
skill  in  newly  evolved  technical  matters.  The 
possession  of  this  technical  skill  is  the  best  capi- 
tal the  beginner  in  practice  has,  and  in  a  clinical 
laboratory  such  as  I  propose  it  could  be  made 
available  for  those  who  have  the  clinical  ne- 
cessity for  its  use.  Particularly  is  this  im- 
portant in  relation  to  the  subject  of  the  obser- 
vation of  blood-pressure,  because  the  condi- 
tions involved  are  not  truly  represented  by  the 
patients  who  are  congregated  in  hospitals  and 
clinics.  Disorders  of  blood-pressure,  while 
found  in  all  classes,  present  particular  phe- 
nomena among  the  upper  grades  of  society. 

Bearing  upon  this  question  we  would  quote 
from  an  article  by  Drs.  Ruth  and  Rider,  en- 
titled "  Laboratory  Aids  in  Clinical  Diagno- 
sis/' which  appeared  in  the  Journal  of  the 
^American  Medical  Association,  May  7,  1904. 

"...  The  solution  of  the  problem  lies  in 
co-operation.      With   an   expenditure  of   $10, 

Note. — The     "Laboratory    of     Clinical     Ohsevvation "    was 
founded  1904,  at  616  Madison  Ave.,  New  York. 


THE  ESTIMATION  OF  BLOOD-PRESSURE     99 

and  an  arrangement  with  a  laboratory  within 
twenty-four  hours'  ride,  any  physician  can 
have  laboratory  advantages  at  his  disposal. 
All  that  is  needed  is  a  few  glass  slides,  some 
culture  lubes,  platinum  needle,  alcohol  lamp, 
Thoma-Zeiss  white  cell  pipette,  Tallquist  hem- 
oglobinometer,  and  a  book  on  technic,  how 
to  obtain  and  forward  material  for  a  leu- 
cocyte count,  hemoglobin  estimation,  bacterio- 
logic  examination  of  blood,  urine,  exudate,  or 
whatever  else  may  be  desired.  One  member  of 
the  community  of  physicians  can  go  to  the  ex- 
pense of  fitting  a  laboratory  and  becoming  pro- 
ficient in  technic.  His  neighbors  can  either 
share  the  expense  and  go  there  to  make  their 
examinations,  or,  what  is  better  perhaps  for 
both,  have  one  who  has  the  time  and  taste  do 
the  work  for  all.  Practice  makes  perfect,  and 
better  observatidhs  would  be  secured  by  such  a 
plan.  A  mutual  agreement  should  be  made  as 
to  the  sharing  of  expense,  and  by  a  very  small 
personal  outlay  a  town  possessing  a  faculty  of 
only  six  or  more  physicians  could  have  a  suf- 
ficiently well-equipped  laboratory  and  afford 
enough  work  to  enable  one  or  more  of  their 


100  BLOOD-PRESSURE 

number  to  become  reasonably  expert.  We 
have  not  the  time  to  elaborate  this  plan,  but 
simply  wish  to  state  how,  b}^  means  of  har- 
mony and  mutual  aid,  it  would  be  possible  to 
bring  the  means  of  diagnostic  precision  within 
the  reach  of  practically  all  the  profession. 

"  In  many  of  the  larger  cities  municipal  labo- 
ratories have  been  established,  and  have  done 
much  good  work,  especially  in  dealing  with  the 
epidemic  and  contagious  diseases.  Being 
municipal  laboratories  only,  they  reach  but 
a  small  proportion  of  the  profession.  It  is  not 
unlikely,  in  view  of  the  good  work  done  by  the 
city  laboratories,  that  the  State  will  eventually 
place  at  the  disposal  of  the  general  profession 
an  adequate  number  of  well-equipped  labora- 
tories that  would  not  only  offer  technical  aid 
in  general  diagnosis,  but  would  require  that 
their  services  be  employed  in  all  cases  that 
might  have  a  bearing  on  the  health  of  the  gen- 
eral public.  It  must  of  necessity  be  some  time 
before  any  generally  efficient  State  aid  can  be 
expected,  and  meanwhile  the  profession  must 
rely  on  their  own  efforts  to  obtain  laboratory 
aid  in  diagnosis." 


NITRITES  FOR  ITS  MODlFICATIOK       ]0l 

The  other  point  that  we  wish  to  make  in  this 
chapter  is  the  necessity  for  greater  conservatism 
in  the  use  of  vaso-dilators  in  certain  cases  of 
cardiovascular  disease.  In  the  career  of  every 
form  of  treatment  there  are  several  stages. 
The  first  is  discussion,  then,  skepticism  having 
been  overcome,  adoption.  The  second  is  intel- 
ligent application  in  the  light  of  previous  dis- 
cussion and  the  consequent  general  informa- 
tion. Third,  the  routine  use  of  an  accepted 
treatment  as  a  matter  of  course  in  a  particular 
disease. 

When  Brunton  applied  amyl  nitrite  to  the 
treatment  of  angina  pectoris,  he  achieved  a 
signal  triumph  in  therapeutics.  Not  less  was 
the  triumph  of  the  more  gradual  application  of 
the  nitrites  in  general  to  the  treatment  of  vas- 
cular spasm.  These  were  first  well  used  by 
those  who  had  witnessed  their  development 
and  were  familiar  with  their  philosophy  and 
limitations.  Unfortunately  the  student  coming 
later  upon  the  field  of  medicine,  and  finding 
the  nitrites  in  general  use  for  vascular  disease, 
jumped  naturally  to  the  conclusion  that  they 
were   the   remedies  par  excellence   and  used 


102  BLOOD-PRESSURE 

them  in  a  routine  way  in  the  treatment  of  these 
cases.  The  obseryation  of  this  fact  makes  it 
seem  useful  at  this  time  to  emphasize  the  neces- 
sity of  some  conservatism  in  this  matter.  It  is  a 
trite  saying  that  we  should  always  treat  the 
patient  and  not  the  disease,  meaning  by  this 
that  we  must  carefully  recognize  the  exact 
physiologic  and  pathologic  conditions  present, 
and  so  influence  them  as  to  bring  about  the 
cure  of  disease.  Patients  differ  widely  in  their 
behavior  under  the  nitrites,  and  for  that  reason 
every  case  requires  physiologic  study  to  de- 
termine the  amount  of  drug  necessary  and 
how  it  should  be  applied. 

There  is  no  more  important  function  of  the 
physician  than  the  early  recognition  of  that 
tendency  to  degeneration  and  death  that 
comes ,  prematurely  to  so  many  of  the  human 
race.  This  shows  most  often  in  arterial 
changes,  one  of  the  earliest  symptoms  of 
which  is  alteration  in  blood  tension.  The 
tension  of  the  blood-vessels  in  health  is  main- 
tained at  an  even  point  through  the  action  of 
the  unstriped  muscular  tissue  in  the  walls  of 
the  blood-vessesls.     The  heart  is  a  part  of  the 


NITRITES  FOR  ITS  MODIFICATION       103 

circulatory  tubes,  and  differs  only  in  arrange- 
ment and  degree  from  the  mechanism  of  the 
rest  of  the  circulatory  path.     It  contains  un- 
striped  muscular  fiber  as  do  the  blood-vessels, 
and  an  arrangement  of  valves  as  do  the  veins. 
Its   muscular   action    is    rhythmic,    while   the 
muscular  action  of  the  blood-vessels  is  only 
slightly  so.    Both  are  subject  to  the  control  of 
the  nervous  system.     It  is  in  the  disordered 
action  of  all  these  muscles  that  the  first  signs 
of  degeneration  appear.     The  muscles  in  the 
vessels  act  badly,  the  muscle  in  the  heart  is  ir- 
ritated, and  the  result  is  tension.     To  apply 
vaso-dilators  without  also  instituting  hygienic 
measures  to  reduce  the  irritability  of  the  heart 
and  restore  the  disordered  or  exhausted  nerv- 
ous system,   is  to  overlook  an  important  ele- 
ment in  the  problem  of  cure. 

The  necessity  for  the  use  of  vaso-dilators  is 
diminished  in  proportion  to  the  intelligence 
and  success  attending  these  accessory  meas- 
ures. In  Bright's  disease  there  is  probably 
some  substance  circulating  in  the  blood  that 
irritates  the  muscular  coats  of  the  vessels  and 
causes   contraction.      This,   with   the   physio- 


104  BLOOD-PRESSUEE 

logic  attempt  of  the  heart  to  carry  on  the 
circulation,  again  brings  about  high-tension. 
When  high-tension  antedates  the  onset  of  ne- 
phritis it  may  well  be  supposed  that  the  ten- 
sion has  something  to  do  with  the  production 
of  nephritis. 

A  physiologic  increase  of  blood-pressure  is 
caused  whenever  there  is  nervous,  muscular,  or 
physiologic  exertion. 

Prolonged  nervous  strain,  such  as  that  met 
with  in  an  exciting  business  career,  or  in  pro- 
longed dissipation,  keeps  up  a  tendency  to  ten- 
sion that  is  particularly  apt  to  lead  to  arterial 
degeneration.  Muscular  action  is  less  prone  to 
produce  damage,  and  probably  does  so  only  in 
rare  instances  of  long  training  and  severe  con- 
tests of  strength.  The  reason  for  this  is  that 
exercise  is  accompanied  by  natural  dilatation 
of  the  arterial  circulation,  improved  nutrition, 
and  relief  afforded  by  perspiration.  The 
physiologic  activities  of  the  body  are  usually 
accompanied  by  too  slight  a  stimulation  of  the 
circulation  to  count  for  much  in  health,  but  are 
worth  considering  in  disease. 

In  the  case  of  a  person  suffering  from  ab- 


NITRITES  FOR  ITS  MODIFICATION       105 

normal  tension  it  is  especially  important  to  do 
away  with  mental  strain  and  responsibility. 
Such  a  person,  should  not  indulge  in  violent 
exercise,  but  is  benefited  by  slow  exercise. 
Food  should  be  moderate  in  amount,  taken  at 
frequent  intervals.  Sugar  and  alcohol  should 
be  done  away  with  entirely  if  possible,  and 
meat  used  only  in  Limited  amount. 

When  the  vaso-dilators  are  given  it  is  to 
produce  a  definite  physiologic  effect  which  is 
capable  of  being  appreciated  by  the  observer. 
The  dose  required  to  produce  this  effect  differs 
widely  in  different  individuals  and  under  dif- 
ferent circumstances.  In  a  large  number  of 
cases  they  are  now  so  given  that  no  effect  what- 
ever is  produced.  Crude  therapeutic  thought  is 
responsible  for  this.  The  idea  is  conceived  that 
the  nitrites  are  good  for  kidney-  and  heart-dis- 
ease, and  so  they  are  administered  with  the 
hope  that  the  patient  may  be  benefited  thereby. 
If  improvement  takes  place  the  medicine  re- 
ceives the  credit,  whether  it  has  done  its  work 
or  not.  The  word  "  conservatism "  means 
more  than  caution,  more  than  small  dosage.  It 
means  the  working  out  of  the  possibilities  of 


106  BLOOD-PRESSURE 

the  remedy  and  its  application  in  such  a  way  as 
to  fulfil  its  broadest  mission,  so  that  it  may  not 
be  wasted  or  abused — wasted  w^hen  used  in 
non-active  doses,  and  abused  when  used  too 
often,  or  in  too  great  quantity.  With  the  vaso- 
dilators a  careful  regulation  of  the  dose  is  of 
vital  importance,  for  their  final  action  may  be 
dilatation  and  paralysis  of  the  heart  through  a 
complete  breaking  down  of  that  great  power 
called  inhibition  which  moderates  all  muscular 
activity. 

When  nitrites  are  used  it  is  also  of  the  utmost 
importance  that  the  preparation  selected  should 
be  reliable.  I  have  known  patients  to  take  for 
a  long  time  tablets  supposed  to  be  nitroglycerine 
which  were  subsequently  found  to  be  inert. 
When  no  benefit  is  obtained  in  conditions  in 
which  nitroglycerine  is  clearly  indicated  this 
may  be  fairly  suspected.  As  a  test,  one  of  the 
tablets  should  be  given  to  a  healthy  person,  who 
should  immediately  feel  the  throbbing  in  the 
head  due  to  the  dilated  blood-vessels  and  the 
stimulation  of  the  heart.  If  no  effect  is  felt,  a 
new  preparation  must  be  sought  and  this  tested. 
The  I  per  cent,  solution  of  glonoin  is  probably 


NITRITES  FOR  ITS  MODIFICATION       107 

more  reliable,  but  is  not  nearly  so  convenient 
for  patients  as  the  tablet. 

Cases  must  be  studied  from  time  to  time  by 
the  withdrawal  of  these  drugs,  and  by  the  sub- 
stitution of  other  drugs  of  a  different  class. 
Particularly  is  it  important  in  every  such  case  to 
know  from  actual  observation  the  effect  of 
digitalis  in  such  doses  as  bring  about  dis- 
tinct physiologic  phenomena. 

But  few  diseases  can  be  treated  by  specific 
measures,  and  cardiovascular  disease  is  par- 
ticularly remote  from  such  an  ideal.  The  end 
which  drugs  accomplish  is  to  so  control  the  cir- 
culation as  to  tend  to  benefit  the  condition 
of  the  tissues,  or  to  prevent  the  condition  of 
these  tissues  from  working  injury  to  the  body 
as  a  whole.  The  management  of  cardiovas- 
cular disease  is  like  the  running  of  an  intri- 
cate machine.  The  physician  must  study  the 
machine  itself  and  learn  all  its  resources.  He 
must  know  the  use  of  every  tool,  and  the  ef- 
fect of  the  turning  of  each  screw.  It  is  no 
abuse  of  the  privileges  of  the  physician  to  study 
his  cases  therapeutically  by  testing  from  time 
to  time  the  effect  of  different  classes  of  drugs, 


108  BLOOD-PRESSURE 

though  he  return  after  each  trial  to  the  original 
plan  of  treatment.  It  is  the  height  of  arro- 
gance to  assume  that  his  inductive  reasoning 
can  plan  for  each  case  a  permanent  course  of 
management.  Such  action  will  only  lead  to 
humiliation  and  disappointment.  How  exas- 
perating it  is  when  for  a  long  period  of  time, 
on  theoretic  grounds,  we  have  abstained  from 
the  use  of  such  a  drug  as  digitalis  to  find  some 
time  or  other  that  our  patient  has  taken  it 
through  the  advic  of  the  corner  druggist  and 
has  received  appreciable  benefit  from  it.  Of 
course,  we  know  very  well  that  the  corner 
druggist  had  no  right  to  experiment,  but  per- 
haps the  risk  was  worth  taking  after  all. 

There  is  a  particular  form  of  pulse  in  which 
nitroglycerine  is  not  as  valuable  as  a  number  of 
other  drugs.  This  is  a  high-tension  pulse 
with  persistently  rapid  heart-action.  In  these 
cases  I  have  sometimes  seen  the  greatest  benefit 
from  the  use  of  digitalis.  Nitroglycerine  has  a 
twofold  action  in  stimulating  the  heart  and  di- 
lating the  blood-vessels.  Digitalis  has  a  two- 
fold action  in  slowing  the  heart  and  contract- 
ing the  blood-vessels.     Theoretically  digitalis 


NITRITES  FOR  ITS  MODIFICATION       109 

would  not  act  in  these  cases,  but  practically  in 
a  case  of  nephritis  with  a  high-tension  and 
rapid  pulse,  digitalis  will  often  show  its  con- 
trolling action  upon  the  heart  in  greater  de- 
gree than  any  of  its  other  effects,  and  in  that 
way  bring  about  a  slower  pulse  with  less  ap- 
parent tension.  At  the  same  time  digitalis  will 
clear  up  congestion  of  the  kidneys  and  cause  a 
better  secretion  of  urine. 

Even  when  tension  does  c  :ist  in  cardiovas- 
cular  disease  with  nephritis,  it  should  be  real* 
ized  that  some  tension  may  be  desirable.  Ae 
time  goes  on  in  such  a  case,  the  greatest  dangej^^ 
to  be  feared  is  a  too  great  lowering  of  the  blood 
tension  with  its  accompanying  congestions  and 
effusions.  In  the  presence  of  symptoms  indi- 
cating disturbances  of  cerebral  circulation,  stich 
as  numbness  or  awkwardness  of  one  of  the  ex- 
tremities, or  slight  difficulty  in  speech,  the 
vaso-dilators  are  imperatively  needed.  Sodium 
iodid  has  also  an  undoubted  power  to  postpone 
paralytic  attacks  due  to  the  plugging  of  blood- 
vessels. 

'A  word  as  to  the  possibility  of  recovery  from 
cardiovascular  degenerative  disease.    The  heart 


no  BLOOD-PRESSURE 

symptoms  are  those  of  myocarditis,  and  the 
kidney  symptoms  those  of  chronic  nephritis. 
The  tendency  of  the  blood  is  to  become  of 
poor  quahty.  With  a  properly  planned  regi- 
men and  the  possibility  of  carrying  it  out,  and 
with  careful  medication  and  other  therapeutic 
measures,  the  heart  may  recover  its  tone  so 
that  all  symptoms  of  degeneration  will  dis- 
appear, and  the  kidneys  may  settle  down  to  do 
their  work  according  to  a  particular  plan,  but 
well  enough  for  the  maintenance  of  health. 

It  is  hard  to  prove  the  regeneration  of  kid- 
ney tissue,  though  the  physiologic  hypertrophy 
of  one  kidney  when  the  other  is  removed  leads 
to  a  belief  in  its  possibility.  Certainly  there 
are  many  persons  passing  a  large  quantity  of 
urine  of  low  specific  gravity,  and  with  a  slight 
trace  of  albumin,  who  maintain  year  in  and 
year  out  signs  of  health.  Their  hearts,  blood- 
vessels, and  kidneys  have  readjusted  them- 
selves, and  though  bearing  the  scars  of 
disease  are  carrying  on  the  functions  of 
the  body  in  a  satisfactory  manner.  I  have 
pictured  this  condition  because  it  is  extremely 
interesting  to  decide  in  these  cases  how  much 


NITRITES  FOR  ITS  MODIFICATION       HI 

we  should  intervene  with  drugs  to  alter  the 
heart-action  or  relax  the  blood-vessels.  It 
seems  to  me  that  in  the  absence  of  symptoms 
sodium  iodid  will  accomphsh  the  best  purpose, 
and  that  the  use  of  the  nitrites  should  be 
limited. 

The  hypertonicity  of  the  arteries  found  as  a 
part  of  nature's  attempt  to  compensate  for  a 
failing  heart  muscle  and  present  in  many  cases 
of  secondary  low  blood-pressure  must  be  dis- 
tinguished from  high  blood-pressure.  The 
contraction  of  the  arteries  disappears  upon  the 
recovery  of  the  power  of  the  heart  to  fill  them 
with  blood. 


CHAPTER  X 

THE  BLOOD-VESSEL  TONE-MAINTAINING  FUNC- 
TION OF  THE  BRAIN 

The  maintenance  of  tone  in  the  muscular 
coats  of  the  blood-vessels  is  so  essential  to  the 
continuance  of  life  and  health  that,  when  it 
fails,  death  follows  in  a  very  few  moments. 
The  capacity  of  the  hollow  organs  that  contain 
the  blood,  when  completely  relaxed,  is  so  great 
that  the  blood  in  the  body  can  only  fill  them  to 
the  extent  of  one-third.  It  is  evident  that  the 
complex  movements  of  the  blood,  constituting 
the  circulation,  cannot  be  carried  on  in  a  sys- 
tem of  tubes  that  are  only  one-third  filled. 
The  circulation  is,  therefore,  dependent  not 
only  upon  the  muscular  contractions  of  the 
heart,  but  also  those  of  the  blood-vessels.  In 
the  course  of  evolution  from  the  lower  to  the 
higher  animals,  there  is  found  in  the  earlier 
stages  a  simple  tube,  and  this  gradually  be- 

m 


THE  BLOOD-VESSEL  AKt)  THE  BRAIK    113 

comes  more  and  more  changed  until  in  its 
course  there  are  developed  special  collections  of 
muscles,  known  as  hearts,  and  when  we  get  to 
the  higher  animals  we  find  the  greatly  dif- 
ferentiated single  organ,  as  in  man. 
--  So,  while,  of  course,  in  man  the  heart  is 
relatively  of  great  importance,  still  the  muscles 
that  remain  in  the  blood-vessels  are  absolutely 
essential  to  the  maintenance  of  the  circulation. 
In  the  control  of  the  muscles  of  the  heart  and 
blood-vessels  there  comes  into  play  a  complex 
arrangement  of  nerves  and  nerve  centers  that 
is  only  secondary  in  its  awe-inspiring  perfec- 
tion to  the  machinery  of  the  intellect  itself. 

As  we  trace  the  development  of  the  circula- 
tion from  the  lower  forms  of  life  up  through 
the  scale,  we  find  that  the  control  moves  closer 
and  closer  to  the  central  nervous  system.  In 
the  higher  forms  of  animals  a  tone-maintaining 
function  is  easily  traced  to  the  medulla,  and  the 
author  believes  that  in  man,  at  least,  an  im- 
portant part  of  this  function  is  found  in  the 
cerebral  hemispheres. 

It  is  w^ell  known  that  there  is  a  tone-main- 
taining influence  originating  in  the  motor  areas 


114  BLOOD-PRESSURE 

of  the  brain  that  presides  over  the  tonicity  of 
the  voluntary  muscles.  When  a  stroke  of 
paralysis  occurs,  due  to  damage  to  the  part  of 
the  brain  that  presides  over  the  motion  of  a 
limb,  that  limb  is  paralyzed  with  regard  to 
voluntary  motion,  but  at  the  same  time  there 
occurs  a  relaxation,  a  loss  of  tone,  in  the  blood- 
vessels that  causes  swelling.  This  suggests 
the  fact  that  the  involuntary  muscles  were  like- 
wise involved  in  a  loss  of  tone,  and  would  seem 
strong  evidence  of  this  blood-vessel  tone-main- 
taining function.  Not  only  may  local  blood- 
vessel tone  be  affected  by  changes  that  occur  in 
the  brain,  but  also  the  general  tonicity  of  the 
whole  circulatory  system.  In  all  brain  condi- 
tions we  look  for  changes  in  the  peripheral 
circulation.  Emotion  may  cause  a  rapid  rise 
of  blood-pressure.  It  is  said  that  insane 
asylums  are  full  of  high-pressure  cases  due  to 
cerebral  excitement.  In  cerebral  neurasthenia 
the  blood-pressure  is  apt  to  be  low. 

In  advocating  the  recognition  of  a  blood-ves- 
sel tone-maintaining  function  of  the  brain  it  is 
not  necessary  to  minimize  the  importance  of  the 
center  in  the  medulla,  whose  actiwties  in  this 


THE  BLOOD-VESSEL  AND  THE  BRAIN    li5 

direction  are  so  well  known.  It  is  only  neces- 
sary to  believe  that  the  activity  of  this  center  is 
dependent  upon  stimulation  received  from  the 
brain.  A  recognition  of  this  function  of  the 
brain,  which  exercises  a  general  control  over  a 
vessel'tone,  and  therefore  over  blood-pressure, 
makes  it  much  easier  to  understand  many  im- 
portant disorders  of  the  circulation  and  the 
benefits  of  certain  plans  of  treatment  experi- 
ence has  proved  of  the  greatest  value. 

It  explains  why  exercise  of  the  voluntary 
muscles  has  so  good  an  influence  over  disorders 
of  the  tone  of  the  involuntary  muscles.  It 
makes  clear  why  resistance  exercises  have 
vindicated  their  right  to  a  place  in  the  treat- 
ment of  disease  of  the  heart.  It  also  reveals 
the  development  and  points  the  way  to  treat- 
ment of  a  disease,  the  importance  of  which  is 
becoming  more  and  more  recognized  every 
day,  and  which  we  will  discuss  in  the  next 
chapter,— Hypertonia  Vasorum  Idiopathica. 


CHAPTER  XI 

HYPERTONIA   VASORUM    IDIOPATHICA 

This  is  par  excellence  the  disease  of  the 
present  day,  and  is  looming  up  as  of  more  and 
more  importance  in  proportion  as  it  is  better 
understood.  The  time  cannot  be  remembered 
when  successful  men  were  not  stricken  down  in 
the  midst  of  their  activities  by  apoplexy  or  so- 
called  heart  failure.  Of  late  years,  it  is  in- 
creasingly common  for  those  men  and  women 
who  play  the  most  prominent  part  in  the  world, 
and  carry  the  heaviest  burden  of  responsibility, 
to  develop  finally  disorders  of  the  arteries  of 
the  brain  or  of  other  vital  organs,  resulting  on 
the  one  hand  in  apoplexy,  or  on  the  other  in 
Bright's  disease.  We  have  attributed  these 
breakdowns  too  often  to  chemical  causes  aris- 
ing from  disorders  of  the  digestive  system,  or 
we  have  regarded  them  as  primarily  disease  of 

116 


HYPERTONIA  VASORUM  IDIOPATHIC  A   ll^ 

the  kidney,  developing  in  some  mysterious 
way.  Too  often  has  alcohol  been  blamed  when 
in  reality  it  was  hardly  a  factor  in  the  case. 
Why  should  it  be  that  persons  preeminent  for 
the  use  of  their  brains,  and  singled  out  for  the 

4. 

heaviest  responsibilities,  suffer  in  the  direction 
of  the  circulation  so  much  more  than  those 
whose  occupation  is  of  another  character? 
The  reason  is  to  be  found  in  the  effect  of 
mental  strain  in  exaggerating  that  tone-main- 
taining function  of  the  brain  that  was  dis- 
cussed in  the  previous  chapter. 

Let  us  trace  the  development  of  such  a  case, 
resulting  in  an  attack  of  apoplexy.  A  com- 
posite picture,  drawn  from  the  mental  concept 
of  this  disease,  tallies  almost  line  by  line  with 
many  concrete  examples.  The  patient  is  a 
man  of  good  family  history,  inheriting  sturdy 
qualities  from  an  ancestry  that  has  developed 
strength  through  the  successful  contest  with 
the  difficulties  of  the  development  of  a  new 
country.  He  has  been  well  educated,  and  has 
led  a  healthy  and  active  youth.  From  the  very 
beginning  he  has  been  a  worker  among  his 
fellows,  and  spurred  on  by  one  success  after 


1 1 8  BLOOD-PRESSURE 

another,  by  middle  life  he  has  attained  a  posi- 
tion of  importance  and  usefulness.  Now  his 
qualities  have  been  recognized,  and  one  burden 
after  another  has  been  laid  upon  him.  He  has 
become  a  factor  in  government,  in  business,  in 
intellectual  pursuits,  and  in  philanthropy. 
Such  a  man,  unmindful  of  the  fact  that 
he  is  past  middle  age,  and  that  the  body  no 
longer  has  the  recuperative  power  of  youth, 
continues  his  work  unceasingly,  without  those 
relaxations  that  attract  men  of  a  lighter  turn  of 
mind.  The  man  feels  perfectly  well,  but  a 
change  has  taken  place  in  the  machinery  of  his 
body.  The  influence  from  the  central  nervous 
system,  which  maintains  the  blood-vessels  in  a 
proper  state  of  tonicity,  has  become  exag- 
gerated through  the  overflowing  of  the  mind 
strain,  and  the  blood  no  longer  circulates  with 
ease.  Now  it  is  hard  for  the  heart  to  keep  the 
blood  in  proper  circulation,  but  without  any 
manifest  symptoms  it  becomes  enlarged  and 
still  carries  on  the  w^ork.  The  two  factors  of 
arterial  contraction  and  cardiac  hyperactivity 
result  in  high  arterial  tension.  This  in  turn 
results  in  structural  damage  to  the  blood-vessels 


HYPERTONIA  VASORUM  IDIOPATHICA    119 

in  the  brain,  the  kidneys  and  elsewhere.  Un- 
consciously, the  man  is  living  in  constant  dan- 
ger. Some  day  there  arises  some  incident  in 
the  man's  career  that  leads  to  an  unusual  de- 
,gree  of  worry  or  mental  strain,  and  there 
develops  a  tendency  to  inflammation  in  the 
already  damaged  blood-vessels  of  the  brain,  and 
the  blood  clots  and  stops  the  circulation,  most 
likely  in  the  speech  center  on  the  left  side,  and 
another  prominent  man  has  fallen  victim  to  an 
attack  of  apoplexy.  Sometimes  the  picture  is 
varied  and  one  of  the  arteries  that  supply  the 
heart  substance  with  blood  is  stopped,  and  the 
man  drops  dead  in  his  tracks;  or  in  another 
case  the  kidneys  gradually  give  out.  Not  in- 
frequently the  abdominal  arteries  show  the  first 
indications  by  terrific  digestive  disturbance 
causing  great  distention  of  the  stomach  with 
wind  and  marked  irregularity  of  the  heart. 
This  is  my  mental  concept  of  hypertonia  vaso- 
rum. 

Even  after  any  one  of  these  serious  acci- 
dents much  can  be  done  for  a  man  made  of 
such  good  stuff,  but  how  much  more  satis- 
factory would  be  the  prevention  of  such  an 


120  BLOOD-PRESSURE 

accident  by  proper  medical  treatment  and  a 
suitable  regimen. 

I  would  like  to  register  a  protest  against 
those  who  decry  the  use  of  drugs  in  circulatory 
disease,  because  in  all  medicine  there  is  no 
condition  in  which  proper  drug  treatment  is 
of  greater  value,  and  none  in  which,  to  my 
mind,  its  usefulness  seems  more  easily  demon- 
strated. The  remedies  must,  however,  be  used 
with  appreciation  of  the  fact  that  they  are  to 
regulate  an  active  mechanism  that  is  always 
changing  in  its  demands,  and  that  the  one 
needed  at  one  time  may  be  contraindicated  a 
little  later. 

This  implies  very  careful  medical  super- 
vision, particularly  when  the  case  first  comes 
under  treatment.  By  a  process  of  re-educa- 
tion of  physiological  processes  control  of  func- 
tion becomes  easier  and  easier,  and  as  the 
patient  becomes  familiar  with  his  tendencies, 
the  physician  can  in  a  measure  yield  control. 
The  details  of  treatment  must  be  worked  out 
for  each  individual  with  due  regard  to  the 
relation  of  blood-pressure,  heart  disease  and 
blood-vessel  damage. 


\ 


1^ 


